Toward More Efficient Surveillance of Barrett’s Esophagus: Identification and Exclusion of Patients at Low Risk of Cancer
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Endoscopic surveillance of Barrett’s esophagus (BE) is probably not cost-effective. A sub-population with BE at increased risk of high-grade dysplasia (HGD) or esophageal adenocarcinoma (EAC) who could be targeted for cost-effective surveillance was sought.
The outcome for BE surveillance from 2003 to 2012 in a structured program was reviewed. Incidence rates and incidence rate ratios for developing HGD or EAC were calculated. Risk stratification identified individuals who could be considered for exclusion from surveillance. A health-state transition Markov cohort model evaluated the cost-effectiveness of focusing on higher-risk individuals.
During 2067 person-years of follow-up of 640 patients, 17 individuals progressed to HGD or EAC (annual IR 0.8%). Individuals with columnar-lined esophagus (CLE) ≥2 cm had an annual IR of 1.2% and >8-fold increased relative risk of HGD or EAC, compared to CLE <2 cm [IR—0.14% (IRR 8.6, 95% CIs 4.5–12.8)]. Limiting the surveillance cohort after the first endoscopy to individuals with CLE ≥2 cm, or dysplasia, followed by a further restriction after the second endoscopy—exclusion of patients without intestinal metaplasia—removed 296 (46%) patients, and 767 (37%) person-years from surveillance. Limiting surveillance to the remaining individuals reduced the incremental cost-effectiveness ratio from US$60,858 to US$33,807 per quality-adjusted life year (QALY). Further restrictions were tested but failed to improve cost-effectiveness.
Based on stratification of risk, the number of patients requiring surveillance can be reduced by at least a third. At a willingness-to-pay threshold of US$50,000 per QALY, surveillance of higher-risk individuals becomes cost-effective.
KeywordsIntestinal Metaplasia Surveillance Program QALY Gain Surveillance Interval Index Endoscopy
Incremental cost-effectiveness ratio
Incidence rate ratio
Quality-adjusted life year
Dr. Mats Lindblad was supported by Bengt Ihre Gastroenterology Fund and Swedish Society of Medicine Traveling Fund. Professor Watson and Professor Fraser received a Beat Cancer Hospital Research Package Grant which was funded by the Cancer Council of South Australia’s Beat Cancer Project on behalf of its donors and the State Government of South Australia Department of Health, together with the support of the Flinders Medical Centre Foundation, its donors and partners. This Grant funded Dr. Gang Chen’s salary.
Authors ML and DW contributed substantially to the conception and design of the work. ML, TB, AS, JB, GM, PG, RF, PB, and DW contributed to data acquisition. Analysis and interpretation of data was performed by ML, TB, GM, GC, PG, RF, and DW. GC, LG, and GM developed the health economic modeling. ML, TB, GM, GC, RF, PG, and DW have participated in drafting the work or revising it critically for important intellectual content. All authors have approved the version submitted and agree in all aspects of the work.
Compliance with ethical standards
Conflict of interest
There are no competing interests or conflicts of interests to disclose among the authors.