Background & Aims
It is important to identify patients with Barrett's esophagus (BE), the precursor to esophageal adenocarcinoma (EAC). Patients with BE are usually identified by endoscopy, which is expensive. The cytosponge, which collects tissue from the esophagus non-invasively, could be a cost-effective tool for screening individuals with gastroesophageal reflux disease (GERD), who are at increased risk for BE. We developed a model to analyze the cost effectiveness of using cytosponge in first-line screening of patients with GERD for BE with endoscopic confirmation, compared to endoscopy screening only,
Methods
We incorporated data from a large clinical trial of cytosponge performance into 2 validated microsimulation models of EAC progression (the esophageal adenocarcinoma model from the Massachusetts General Hospital and the microsimulation screening analysis model from Erasmus University Medical Center). The models had been calibrated for United States Surveillance, Epidemiology and End Results data on EAC incidence and mortality. In each model, we simulated the effect of a 1-time screen for BE in male patients with GERD, 60 years of age, using endoscopy alone or cytosponge collection of tissue and analysis for level of trefoil factor 3 with endoscopic confirmation of positive results. For each strategy we recorded the number of cases of EAC that developed, the number of EAC cases detected screening by cytosponge only or by subsequent targeted surveillance, and the number of endoscopies needed. Additionally, we recorded the cumulative costs (including indirect costs) incurred and quality-adjusted years of life lived within each strategy, discounted at a rate of 3% per year, and computed incremental cost-effectiveness ratios (ICERs) among the 3 strategies.
Results
According to the models, screening patients with GERD by cytosponge with follow-up confirmation of positive results by endoscopy would reduce the cost of screening by 38%–41%, compared to screening by endoscopy, but led to 1.8 to 4.0 (per 1000 patients) fewer quality-adjusted life years. The ICERs for cytosponge screening compared to no screening ranged from $28,791 to $33,307. For screening patients by endoscopy compared to cytosponge, the ICERs ranged from $143,041 to $330,361. These results were sensitive to cytosponge cost within a plausible range of values.
Conclusion
In a comparative modeling analysis of screening strategies for BE in patients with GERD, we found cytosponge screening with endoscopic confirmation to be a cost-effective strategy.
The greatest benefit was achieved by endoscopic screening, but with an unfavorable cost margin.
