The optimal age to discontinue surveillance of patients with non-dysplastic Barrett esophagus (NDBE) ranges from 69 to 81 years depending on patients’ sex and general health, according to a study in Gastroenterology.
Investigators used 3 independently developed simulation models of esophageal adenocarcinoma (EAC) screening and surveillance from the Cancer Intervention and Surveillance Modeling Network (CISNET) of the National Cancer Institute. They simulated patients diagnosed with NDBE, varying in age, sex, and comorbidity level.
The study authors calculated incremental costs and quality-adjusted life-years (QALYs) gained from 1 additional endoscopic surveillance at patients’ current age compared with not conducting surveillance at that age. The optimal age to end surveillance was the age at which the incremental cost-effectiveness ratio (ICER) of 1 more surveillance was just below the willingness-to-pay (WTP) threshold of $100,000/QALY.
For men with NDBE and without comorbidities, the researchers found that the optimal age for last surveillance is 81 years, although it may be as many as 8 years earlier for those with comorbidities. For women with NDBE and without comorbidities, the optimal age for last surveillance is 75 years, but it can be up to 6 years earlier for those with comorbidities.
Among men, 1 additional surveillance at age 68 in 1000 patients with NDBE and without comorbidities prevented 10 more EAC cases compared with not conducting surveillance at that age. “Overall, 56 more QALYs were gained at an incremental cost of more than $1 million, resulting in an ICER of $23,600 per QALY, which was well below the WTP threshold,” stated the researchers.
For men with NDBE and comorbidities, the same comparison demonstrated that 1 additional surveillance at age 68 years prevented fewer EAC cases and deaths, which led to higher net costs and lower QALYs. The ICERs were below the WTP threshold, however, and surveillance at age 68 was considered cost-effective for patients with NDBE with all levels of comorbidities. By increasing the age of surveillance for men with NDBE, the net benefits of 1 additional surveillance decreased, and the ICERs increased accordingly.
In women, the net benefits of 1 additional surveillance decreased with increasing age and comorbidities. However, the ICERs of 1 more surveillance in women were generally higher than those for men of similar age and comorbidity status. Surveillance of women aged greater than 75 years, for example, was not cost-effective (ICERs >$101,800/QALY) for any comorbidity level.
In women without comorbidities, 75 years was the optimal age for last surveillance with an ICER of $84,200/QALY. Surveillance of women with higher comorbidity levels was associated with higher ICERs and lower optimal stopping ages.
The researchers noted several study limitations, as they were not able to assess the impact of patient comorbidity levels on the prognosis of cancer. Additionally, the utility values used in the analysis were derived from limited available literature that may not accurately represent the value or quality of patients’ lives.
“Our analysis has important implications for surveillance of NDBE patients,” the investigators commented. They concluded, “In addition to chronological age, the comorbidity status and sex of patients are important factors to inform the decision to discontinue surveillance.”
Omidvari A-H, Hazelton WD, Lauren BN, et al. The optimal age to stop endoscopic surveillance of Barrett’s esophagus patients based on sex and comorbidity: a comparative cost-effectiveness analysis. Gastroenterol. Published online May 8, 2021. doi: 10.1053/j.gastro.2021.05.003