Screening for and surveillance of Barrett’s esophagus: a cost-effectiveness assessment

Esophageal adenocarcinoma (EAC) is the most common type of esophageal cancer in Western countries. Various risk factors are associated with EAC, of which Barrett’s esophagus (BE) is the most important one. Targeted screening of well-defined high-risk populations and surveillance of BE patients using an upper gastrointestinal (GI) endoscopy is recommended by several clinical practice guidelines in the world. However, there are discrepancies in guidelines’ recommendations. In this thesis, we conducted cost-effectiveness analyses on BE screening and surveillance strategies. First, we focused on screening for BE and evaluated the cost-effectiveness of using minimally invasive method to screen high-risk people for BE, and we assessed the impact of including unrelated health effects and costs on our cost-effectiveness estimates. Then, we evaluated several ways to further improve the cost-effectiveness of BE surveillance by optimizing different aspects of BE management. Subsequently, we evaluated how the lack of adherence to surveillance guidelines for BE patients can impact cost-effectiveness estimate

Optimizing Management of Patients With Barrett's Esophagus and Low-Grade or No Dysplasia Based on Comparative Modeling

Background & Aims: Endoscopic treatment is recommended for patients with Barrett's esophagus (BE) with high-grade dysplasia, yet clinical management recommendations are inconsistent for patients with BE without dysplasia (NDBE) or with low-grade dysplasia (LGD). We used a comparative modeling analysis to identify optimal management strategies for these patients. Methods: We used 3 independent population-based models to simulate cohorts of 60-year-old individuals with BE in the United States. We followed up each cohort until death without surveillance and treatment (natural disease progression), compared with 78 different strategies of management for patients with NDBE or LGD. We determined the optimal strategy using cost-effectiveness analyses, at a willingness-to-pay threshold of $100,000 per quality-adjusted life-year (QALY). Results: In the 3 models, the average cumulative incidence of esophageal adenocarcinoma was 111 cases, with costs totaling$5.7 million per 1000 men with BE. Surveillance and treatment of men with BE prevented 23% to 75% of cases of esophageal adenocarcinoma, but increased costs to $6.2 to$17.3 million per 1000 men with BE. The optimal strategy was surveillance every 3 years for men with NDBE and treatment of LGD after confirmation by repeat endoscopy (incremental cost-effectiveness ratio, $53,044/QALY). The average results for women were consistent with the results for men for LGD management, but the optimal surveillance interval for women with NDBE was 5 years (incremental cost-effectiveness ratio,$36,045/QALY). Conclusions: Based on analyses from 3 population-based models, the optimal management strategy for patient with BE and LGD is endoscopic eradication, but only after LGD is confirmed by a repeat endoscopy. The optimal strategy for patients with NDBE is endoscopic surveillance, using a 3-year interval for men and a 5-year interval for women