Barrett's esophagus: A new look at surveillance-based on emerging estimates of cancer risk

OBJECTIVE: Surveillance of Barrett's patients is recommended, to detect dys plasia and early cancer. The reported risk for developing cancer varies sub stantially, however. Our previous analysis used an average cancer incidence of 1/75 patient-years (PY). Recent reports suggest that the risk may range from 1/251 to 1/208 PY in combined series of patients with long segment Ba rrett's esophagus (LSBE, >3 cm), and short segment Barrett's esophagus (SSB E), and up to 1% annually in patients with SSBE. Our goal was to consider t hese new estimates of cancer risk in a cost-utility analysis of surveillanc e of patients with Barrett's esophagus. METHODS: Using our previously published model, we incorporated an average o f the recent estimates of cancer risk (0.4% annually, 1/227 PY), and our pr imary data on quality of life after esophagectomy. We included actual varia ble (direct) costs and used a discount rate of 5%. From the perspective of an HMO, the model evaluates surveillance every 1-5 yr and no surveillance, with esophagectomy performed if high grade dysplasia is diagnosed, and calc ulates the incremental cost-utility ratios for each strategy. RESULTS: The results suggest that, at our baseline, annual cancer risk surv eillance every 5 yr is the only viable strategy. More frequent surveillance costs more and yields a lower life expectancy. The incremental cost-utilit y ratio for surveillance every 5 yr is $98,000/quality-adjusted life year ( QALY) gained, comparable to the incremental cost-effectiveness ratios of ac cepted practices (heart transplantation and screening for tuberculosis in s elected populations, $160,000/LY gained and $216,000/LY gained, respectivel y). CONCLUSIONS: Surveillance of Barrett's patients should extend life, with in cremental cost-utility ratios that compare favorably with some accepted med ical practices. Policy makers can compare the cost of surveillance to that of other accepted practices to determine their willingness to fund surveill ance. (Am J Gastroenterol 1999;94:2043-2053. (C) 1999 by Am. Coll. of Gastr oenterology).