Cost-effectiveness of Endoscopic Surveillance for Gastric Intestinal Metaplasia

Background: Patients with intestinal metaplasia (IM) are at increased risk for gastric cancer. Endoscopic surveillance has been shown to anticipate cancer diagnosis in an earlier stage. Cost-effectiveness of endoscopic surveillance in IM patients is unknown. To assess the efficacy and cost-effectiveness of an yearly endoscopic surveillance in patients with IM. Methods: A decision analysis model was constructed in order to compare a strategy of performing an EGD every year for a 10-year period (surveillance strategy) following a new diagnosis of IM to a policy of nonsurveillance in a simulated cohort of 10,000 American patients. A 1.8% 10-year cumulative incidence of gastric cancer in IM patients was estimated from the literature. Endoscopic surveillance was simulated to downstage the detected cancers by 58-84%. Costs of EGD and cancer care were estimated from Medicare reimbursement data. The main outcome measurement was the incremental cost-effectiveness ratio. Results: The number of EGDs required to detect one cancer and to prevent one gastric cancer-related death in the surveillance arm were 556 and 3738, respectively. The incremental cost-effectiveness ratio of endoscopic surveillance as compared to a nonsurveillance policy was $72,519 per life-year gained (5-95% percentiles Monte Carlo analysis: $54,843-$98,853). At sensitivity analysis, cancer incidence and the rate of downstaging were the most important variables. Conclusions: According to our simulation, the relatively high risk of cancer in patients with IM and the substantial efficacy of endoscopic surveillance in reducing cancer-related mortality would support the cost-effectiveness of an endoscopic surveillance program in patients with IM. Further research is needed before implementing it in the clinical practice.