The Optimal Age to Stop Endoscopic Surveillance of Patients With Barrett’s Esophagus Based on Sex and Comorbidity: A Comparative Cost-Effectiveness Analysis

Abstract

BACKGROUND AND AIMS: Current guidelines recommend surveillance for patients with nondysplastic Barrett’s esophagus (NDBE) but do not include a recommended age for discontinuing surveillance. This study aimed to determine the optimal age for last surveillance of NDBE patients stratified by sex and level of comorbidity. METHODS: We used 3 independently developed models to simulate patients diagnosed with NDBE, varying in age, sex, and comorbidity level (no, mild, moderate, and severe). All patients had received regular surveillance until their current age. We calculated incremental costs and quality-adjusted life-years (QALYs) gained from 1 additional endoscopic surveillance at the current age versus not performing surveillance at that age. We determined the optimal age to end surveillance as the age at which incremental cost-effectiveness ratio of 1 more surveillance was just less than the willingness-to-pay threshold of $100,000/QALY. RESULTS: The benefit of having 1 more surveillance endoscopy strongly depended on age, sex, and comorbidity. For men with NDBE and severe comorbidity, 1 additional surveillance at age 80 years provided 4 more QALYs per 1000 patients with BE at an additional cost of $1.2 million, whereas for women with severe comorbidity the benefit at that age was 7 QALYs at a cost of $1.3 million. For men with no, mild, moderate, and severe comorbidity, the optimal ages of last surveillance were 81, 80, 77, and 73 years, respectively. For women, these ages were younger: 75, 73, 73, and 69 years, respectively. CONCLUSIONS: Our comparative modeling analysis illustrates the importance of considering comorbidity status and sex when deciding on the age to discontinue surveillance in patients with NDBE.

Diagnosis and Management of Barrett's Esophagus: An Updated ACG Guideline

“…From a pragmatic perspective, it is reasonable to cease endoscopic surveillance in patients with an estimated survival of less than 5 years and those who are no longer fit for repeated endoscopy or cannot tolerate endoscopic, surgical, or oncological intervention for esophageal neoplasia. A recent modeling study suggested that the optimal age of last surveillance of a patient with NDBE was between 69 and 81 years and was dependent on the sex and comorbidities of the patient (125). Although it is difficult to be dogmatic given the wide variability in life-limiting comorbidities, given the current average American life expectancy, discussion of cessation of further endoscopic surveillance is merited when most patients reach 75 years of age, if it has not occurred prior.…”

Barrett Esophagus

“…Despite this, some professional organizations (eg, American College of Gastroenterology [ACG], American Society for Gastrointestinal Endoscopy) recommend screening and surveillance for Barrett esophagus. A recent analysis suggested that when determining whether to perform screening or surveillance, the patient’s overall life expectancy (<10 years) should be considered …”

Clinical variation in surveillance and management of Barrett’s esophagus: A cross-sectional study of gastroenterologists and gastrointestinal surgeons

“…While 90% or more of the BE surveillance population has NDBE, representing the majority of a gastroenterologist’s typical BE caseload. [ 32 ] NDBE patients harbors many patients who require proactive management.…”