Surveillance in patients with long-segment Barrett's oesophagus: a cost-effectiveness analysis

Objective Surveillance is recommended for Barrett's oesophagus (BO) to detect early oesophageal adenocarcinoma (OAC). The aim of this study was to evaluate the cost-effectiveness of surveillance. Design We included 714 patients with long-segment BO in a multicentre prospective cohort study and used a multistate Markov model to calculate progression rates from no dysplasia (ND) to low-grade dysplasia (LGD), high-grade dysplasia (HGD) and OAC. Progression rates were incorporated in a decision-analytic model, including costs and quality of life data. We evaluated different surveillance intervals for ND and LGD, endoscopic mucosal resection (EMR), radiofrequency ablation (RFA) and oesophagectomy for HGD or early OAC and oesophagectomy for advanced OAC. The incremental cost-effectiveness ratio (ICER) was calculated in costs per quality-adjusted life-year (QALY). Results The annual progression rate was 2% for ND to LGD, 4% for LGD to HGD or early OAC and 25% for HGD or early OAC to advanced OAC. Surveillance every 5 or 4years with RFA for HGD or early OAC and oesophagectomy for advanced OAC had ICERs of Euro5.283 and Euro62.619 per QALY for ND. Surveillance every five to one year had ICERs of Euro4.922, Euro30.067, Euro32.531, Euro41.499 and Euro75.601 per QALY for LGD. EMR prior to RFA was slightly more expensive, but important for tumour staging. Conclusions Based on a Dutch healthcare perspective and assuming a willingness-to-pay threshold of Euro35.000 per QALY, surveillance with EMR and RFA for HGD or early OAC, and oesophagectomy for advanced OAC is cost-effective every 5 years for ND and every 3 years for LGD.