For which populations is screening for BO cost-effective?
Eight studies were included in this review, which were published between 2000 and 2012. A non-systematic review of the literature which included five of these eight papers was also considered in developing these recommendations. ( Four studies used Markov modelling, three decision analysis and one microsimulation to model the outcomes and associated costs in various hypothetical cohorts. All studies were based on US data with the exception of a single UK study.
All studies compared endoscopic screening versus no screening. In addition, one study also compared ultra-thin endoscopy versus no screening; one study compared capsule endoscopy versus no screening; and one study compared a non-endoscopic cytosponge as the screening test versus no screening. Seven of the eight studies screened populations with a history of gastro-oesophageal reflux disease (GORD), which was defined to varying degrees of precision. Only one study screened an asymptomatic population of 50-year old men and women who were attending for screening colonoscopy. One study included 50-year old men and women with GORD and another study 60-year old men and women with GORD. The other five studies screened 50-year old men with GORD, of which three specified that only white men were included.
Assumptions about the prevalence of Barrett’s Oesophagus and dysplasia varied considerably across studies: prevalence estimates for Barrett’s Oesophagus ranged from 1-10% but were not necessarily consistent across studies for the same hypothetical population. As discussed elsewhere in this guideline, assumptions about other key model estimates such as transition rates and treatment protocols were not consistent across studies or based on robust data. Similarly there was some variation in assumptions about the utilities of different states and none accounted for the potential psychological harms of screening or disutility of chronic GORD. Only three studies included endoscopic therapies for Barrett’s Oesophagus. Importantly estimates of effectiveness are not based on data from randomised controlled trials.
The table below summarises the key findings from the included studies, reporting only the estimates of the incremental cost-effectiveness ratio for the base-case assumptions. All studies report sensitivity analyses for a range of different assumptions for the key model parameters. The prevalence of Barrett’s Oesophagus in the screened population is clearly a major driver of cost-effectiveness.
|Author||Population screened||Prevalence of BO||Incremental cost-effectiveness ratio|
|Inadomi 2003||50-yr white men with GORD||10%||$10,444 per QALY|
|Rubenstein 2006||50-yr white men with GORD||10%||$13,721 per QALY|
|Rubenstein 2007||50-yr white men with GORD||10%||$11,254 per QALY|
|Gerson 2004||50-yr men with GORD||10%||$12,140 per QALY|
|Benaglia 2012||50-yr men with GORD||8%||$22,167 per QALY for endoscopy
$15,724 per QALY for cytosponge
|Nietert 2003||50-yr men and women with GORD||3%||$86,883 per QALY for standard endoscopy
$55,764 per QALY for ultra-thin endoscopy
|Soni 2000||60-yr men and women with GORD||10%||$24,718 per QALY|
|Gupta 2011||50-yr men and women attending for screening colonoscopy||1%||$95,559 per QALY|
QALY = (Quality Adjusted Life Years)
Despite the limitations of the studies discussed already, there is consistent evidence that the most cost-effective strategy is one-off screening of 50-year old men with GORD. This could potentially be refined further to only white men, recognising that this is based on hypothetical populations from the US. The generalisability of this to the Australian population is uncertain. Both the cytosponge and ultra-thin endoscopy may be more cost-effective compared to standard endoscopic screening. Screening men and women with GORD at aged 60 would be an alternative screening model which would still be considered cost-effective on current standards, albeit less so than screening only symptomatic men at 50 years. General population screening, even if conducted coincident with colonoscopy screening, is not cost-effective and would also not be consistent with current Australian recommendations for general population screening for colorectal cancer.
Evidence summary and recommendations
There is no evidence to support general population screening for Barrett’s Oesophagus.
In the absence of Randomised Controlled Trial evidence of effectiveness, screening for Barrett’s Oesophagus would be most cost-effective if limited to 50-year old men with gastro-oesophageal reflux disease.
- Barbiere JM, Lyratzopoulos G. Cost-effectiveness of endoscopic screening followed by surveillance for Barrett's esophagus: a review. Gastroenterology 2009 Dec;137(6):1869-76 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/19840798.
- Nietert PJ, Silverstein MD, Mokhashi MS, Kim CY, Glenn TF, Marsi VA, et al. Cost-effectiveness of screening a population with chronic gastroesophageal reflux. Gastrointest Endosc 2003 Mar;57(3):311-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12612508.
- Gerson LB, Groeneveld PW, Triadafilopoulos G. Cost-effectiveness model of endoscopic screening and surveillance in patients with gastroesophageal reflux disease. Clin Gastroenterol Hepatol 2004 Oct;2(10):868-79 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/15476150.
- Rubenstein JH, Inadomi JM. Defining a clinically significant adverse impact of diagnosing Barrett's esophagus. J Clin Gastroenterol 2006 Feb;40(2):109-15 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/16394870.
- Rubenstein JH, Inadomi JM, Brill JV, Eisen GM. Cost utility of screening for Barrett's esophagus with esophageal capsule endoscopy versus conventional upper endoscopy. Clin Gastroenterol Hepatol 2007 Mar;5(3):312-8 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/17368230.
- Soni A, Sampliner RE, Sonnenberg A. Screening for high-grade dysplasia in gastroesophageal reflux disease: is it cost-effective? Am J Gastroenterol 2000 Aug;95(8):2086-93 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/10950062.
- Inadomi JM, Sampliner R, Lagergren J, Lieberman D, Fendrick AM, Vakil N. Screening and surveillance for Barrett esophagus in high-risk groups: a cost-utility analysis. Ann Intern Med 2003 Feb 4;138(3):176-86 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/12558356.
- Gupta N, Bansal A, Wani SB, Gaddam S, Rastogi A, Sharma P. Endoscopy for upper GI cancer screening in the general population: a cost-utility analysis. Gastrointest Endosc 2011 Sep;74(3):610-624.e2 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/21741639.
- Benaglia T, Sharples LD, Fitzgerald RC, Lyratzopoulos G. Health Benefits and Cost Effectiveness of Endoscopic and Nonendoscopic Cytosponge Screening for Barrett's Esophagus. Gastroenterology 2012 Oct 3 Abstract available at http://www.ncbi.nlm.nih.gov/pubmed/23041329.