Journal Article

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

Bright, Tim, Mayne, George C., Schloithe, Ann, Bull, Jeff, Bampton, Peter A., Gordon, Louisa G., Chen, Gang, Watson, David I., Lindblad, Mats, Gatenby, Piers A., Fraser, Robert J. L.

2017

Overview

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.

• Publisher: Springer International Publishing,John Wiley & Sons, Inc
• Subject: Abdominal Surgery / Aged / Aged, 80 and over / Australia / Barrett Esophagus - pathology / Cardiac Surgery / Cell Transformation, Neoplastic / Cohort Studies / Cost-Benefit Analysis / Female / Follow-Up Studies / General Surgery / Health risks / Humans / Index Endoscopy / Intestinal Metaplasia / Male / Medicine / Medicine & Public Health / Middle Aged / Original Scientific Report / Precancerous Conditions - pathology / QALY Gain / Quality-Adjusted Life Years / Risk Assessment / Surgery / Surveillance Interval / Surveillance Program / Thoracic Surgery / Vascular Surgery / Watchful Waiting - economics