Norio Fukami, MD, is a professor of medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic

Norio Fukami, MD

Early esophageal cancer (EEC) remains a key area of debate in gastroenterology, particularly as minimally invasive endoscopic therapies continue to evolve alongside traditional surgical management. Although endoscopic submucosal dissection (ESD) is widely established in East Asia and increasingly adopted in Europe, uptake in the US has lagged because of technical demands, limited training infrastructure, inconsistent reimbursement, and, until recently, the lack of a dedicated Current Procedural Terminology (CPT) code.

Modeling data presented at Digestive Disease Week 2026 by study investigator Norio Fukami, MD, professor of medicine in the Division of Gastroenterology and Hepatology at Mayo Clinic, spoke with HCPLive to discuss how first-line ESD may offer both survival and cost advantages over esophagectomy for EEC in the United States, potentially strengthening the clinical and economic rationale for expanding access to the procedure.

Model Suggests Survival and Cost Advantages With First-Line ESD

Using a decision-tree model from a US third-party payer perspective, Noromi and investigators simulated a 2-year treatment pathway in a hypothetical cohort of 10,000 patients comparing first-line ESD with first-line esophagectomy. Clinical inputs included perioperative mortality, curative ESD rates, histopathologic distribution, and recurrence risk following curative and noncurative ESD.

Over 2 years, the model projected 84 more survivors with first-line ESD than esophagectomy (9939 vs 9855 per 10,000 patients). First-line ESD was also associated with approximately $97.7 million in cost savings compared with esophagectomy ($291.7 million vs $389.4 million in 2024 US dollars), making ESD both more effective and less costly in the base-case analysis.

Findings May Support Expanded Access to ESD

The model accounted for patients requiring second-line therapy after noncurative ESD, including esophagectomy, chemoradiotherapy for squamous cell carcinoma, or chemotherapy for adenocarcinoma. Even when second-line esophagectomy costs increased by 500%, first-line ESD remained cost-saving. Threshold analysis suggested ESD would continue to be cost-saving if procedural costs remained below approximately $15,300.

HCPLive: Starting off broadly, can you tell me a little bit about the clinical and economic gaps that motivated this research?

Fukami: ESD has been available for the last 20 years or so, and the slow adaptation of ESD in the United States is partly because of training and reimbursement issues. Despite the clinical benefits of the ESD, it requires hours of training leads up to the procedure and availability of ESD for patients was limited. American society’s clinical practice update and guidelines were recently published on indications and lesion characteristics that should be considered for ESD. Yet, reimbursement for ESD needs to be established. We wondered what would the health economic benefit for patients be? There's always an alternative and the traditional treatment is surgery. We have decided to explore which treatment would make the most sense clinically and economically for early esophageal cancer.

We know clinically ESD surpasses surgery for T1a esophageal cancer, because it offers quicker recovery, fewer adverse events, and comparable excellent oncological outcomes. If we can keep the curative resection rate for ESD high, then it’s a no brainer that ESD should be a treatment choice. We decided to include T1 esophageal cancer for the comparative analysis, which includes T1b cancer that is borderline category for ESD. Although T1b cancer may not be cured only by ESD, frequently, patients with esophageal cancer are too afraid and don't want to have major surgery. We can offer ESD as a diagnostic and potentially curative resection for pathological staging and risk stratification. Also, clinical separation of T1a and T1b is very difficult before resection. Once the cancer invades muscularis propria, it is T2 stage and ESD should not be offered. Thus, ESD on T1 esophageal cancer makes most sense to compare with surgical outcomes on T1 esophageal cancer. Roughly, endoscopically removed T1 lesion would consist with 70-80% T1a, and 20-30% T1b.

This study was done in collaboration with Boston Scientific. Outcome measures were survival and cost for the care following a decision tree. A theoretical decision tree with probable outcomes was created together with my co-authors using published data, and the cost for the care was calculated with the published Medicare cost. One primary arm was first line surgical treatment with subsequent events, and the other was first line ESD arm with subsequent events. The calculation was performed up to 2 years. Our calculation was very conservative with the ESD curative rate was set at about 75% which is lower compared to more recent published data. If ESD was not curative, patient proceed to do either surgery, or chemotherapy or chemoradiation. For squamous cell carcinoma, chemoradiation is usually considered over surgery. The overall cost was calculated according to the decision tree with the estimated medical costs. We compared those 2 arms and estimated which arm comes better for patient outcomes and overall healthcare costs.

HCPLive: Your analysis suggests that ESD is both more cost effective and associated with slightly better survival. What do you think of the key drivers behind these differences in outcomes and cost?

Fukami: That's a good question. The lower overall cost is from the lower adverse events with ESD and the higher upfront cost for surgery. Traditionally, we kept the patient in the hospital after ESD, but recent practice tends to require no hospital stay performed as an outpatient procedure, so that the cost is much lower. The cost with first line ESD came out better economically with about 10,000 dollars saving per patient.

HCPLive: How should clinicians think about patient selection when deciding between ESD and esophagectomy, particularly in borderline or more complex early-stage cases?

Fukami: It is best for all the patients and clinicians to select minimally invasive intervention first, whenever possible, especially if it economically makes sense. Patients would gain much more understanding of the stage of disease and the risk of recurrence after the review of a resected specimen after the ESD procedure, which is associated with minimum mortality and significantly less morbidity than surgery. So, I think if the tumor is a T1, this is strong driver to consider endoscopic resection first than surgery. Of course, if the tumor is highly suspected to be deeply invasive to submucosa, which means ESD likely not to offer curative resection, surgery should be considered.

HCPLive: Looking ahead, what additional data or real-world evidence do you think would help solidify the role of ESD as a first line option in early cancer?

Fukami: I strongly believe that ESD is the first line treatment for T1 cancer if the lesion may be removed with clear margins. It has been shown in the retrospective study for esophageal squamous cell carcinoma that first line ESD did not affect patient surgical outcomes, if patients need additional surgery. So, we're not putting patient at additional risk by offering the ESD first. The main issue is the patient selection. We need to make sure that we're not removing the lesions outside of indications, such as tumor with deeper cancer invasion and high likelihood of non-curative resection. So, the detailed diagnostic evaluation should be performed to offer ESD for appropriate target. We need more U.S. data on the pathological outcomes of esophageal ESD, namely margin free resection rate and curative resection rate. This rate includes procedural success as well as appropriateness of patient selection. Two different cancers, adenocarcinoma and squamous carcinoma, have a different implication on patient selection, because squamous cell cancer tend to invade into the vascular structures at earlier tumor stage. However, even for the squamous cell carcinoma, the diagnostic ESD offers pathological prognostication, so that the patient can be guided for additional treatment before proceeding with surgery.

HCPLive: Is there anything else you would like to add or highlight?

Fukami: The calculation of the study is robust. Probability we set for the calculation is advantageous for esophagectomy, because ESD curative resection rate is 75% and the mortality for esophagectomy is less than 2%, which is much higher in the real-world setting. ESD mortality is rarely reported. Despite the advantage, first-line ESD surpassed first line esophagectomy. The cost saving is significant. First-line ESD should be considered as a first line therapy for the overall healthcare cost as well as patients’ benefit. Proper insurance coverage for ESD is strongly recommended to support ESD practice and to make the ESD procedure readily available for any patients with early esophageal cancer who may have a chance of cure by endoscopic procedure. This also likely to reduce overall healthcare cost.

Editor’s Note: Fukami reports no relevant disclosures.

Fukami N, Ganz ML, Faucher S, Cangelosi MJ. Cost-effectiveness analysis of endoscopic submucosal dissection compared with esophagectomy for early esophageal cancer in the United States [abstract]. Presented at: Digestive Disease Week 2026; May 2-5, 2026; Chicago, IL.

Hwang SY, Stirrat T, Zaffar D, Kim RE. Endoscopic submucosal dissection for esophageal cancer: an overview of current indications and challenges to adoption in the United States. 

Articles

Decision-analytic modeling from a US third-party payer perspective compared first-line endoscopic submucosal dissection (ESD) versus esophagectomy over 2 years for 10,000 patients with T1 early esophageal cancer. First-line ESD yielded modestly higher survival (84 additional survivors) and substantial cost savings (~$97.7M; ≈$10K per patient), driven by lower morbidity and avoidance of high upfront surgical costs, increasingly with outpatient ESD. Results remained cost-saving despite large increases in second-line surgery costs, with a procedural cost threshold of ~$15,300.

Fukami, MD, discusses how first-line ESD may offer both survival and cost advantages over esophagectomy for EEC in the United States.