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World Journal of Surgery

, Volume 41, Issue 4, pp 1023–1034 | Cite as

Toward More Efficient Surveillance of Barrett’s Esophagus: Identification and Exclusion of Patients at Low Risk of Cancer

  • Mats Lindblad
  • Tim Bright
  • Ann Schloithe
  • George C. Mayne
  • Gang Chen
  • Jeff Bull
  • Peter A. Bampton
  • Robert J. L. Fraser
  • Piers A. Gatenby
  • Louisa G. Gordon
  • David I. WatsonEmail author
Original Scientific Report

Abstract

Background

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.

Methods

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.

Results

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.

Conclusions

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.

Keywords

Intestinal Metaplasia Surveillance Program QALY Gain Surveillance Interval Index Endoscopy 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Abbreviations

BE

Barrett’s esophagus

CI

Confidence interval

CLE

Columnar-lined esophagus

EAC

Esophageal adenocarcinoma

HGD

High-grade dysplasia

IM

Intestinal metaplasia

ICER

Incremental cost-effectiveness ratio

IR

Incidence rate

IRR

Incidence rate ratio

LGD

Low-grade dysplasia

NA

Not applicable

QALY

Quality-adjusted life year

Notes

Acknowledgements

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.

Author contributions

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.

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Copyright information

© Société Internationale de Chirurgie 2016

Authors and Affiliations

  • Mats Lindblad
    • 1
    • 4
  • Tim Bright
    • 1
  • Ann Schloithe
    • 1
  • George C. Mayne
    • 1
  • Gang Chen
    • 3
  • Jeff Bull
    • 1
  • Peter A. Bampton
    • 2
  • Robert J. L. Fraser
    • 2
  • Piers A. Gatenby
    • 5
  • Louisa G. Gordon
    • 6
  • David I. Watson
    • 1
    • 3
    Email author
  1. 1.Department of SurgeryFlinders University, Flinders Medical CentreAdelaideAustralia
  2. 2.Department of Gastroenterology and HepatologyFlinders UniversityAdelaideAustralia
  3. 3.Flinders Centre for Innovation in CancerFlinders UniversityAdelaideAustralia
  4. 4.Division of Upper Gastrointestinal Surgery, Centre of Digestive Diseases, KarolinskaUniversity HospitalStockholmSweden
  5. 5.Department of SurgeryRoyal Surrey County HospitalGuildfordUK
  6. 6.Centre for Applied Health EconomicsGriffith UniversityBrisbaneAustralia

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