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When to Stop Surveillance for Nondysplastic Barrett’s Esophagus?

NEW YORK (Reuters Health) – In the absence of comorbidities, discontinuing endoscopic surveillance of non-dysplastic Barrett’s esophagus (NDBE) in women in their mid-70s and men in their early 80s may be the most cost-effective approach, according to a comparative analysis.

Barrett’s esophagus is the only known precursor lesion for esophageal adenocarcinoma, Dr. Amir-Houshang Omidvari of Erasmus University Medical Center, in Rotterdam, the Netherlands, and colleagues note in Gastroenterology.

“Esophageal cancer is deadly and the incidence in the U.S. is rising,” Dr. Omidvari told Reuters Health by email. “We believe it is important to perform endoscopy at regular intervals to detect BE at a stage where our treatment can prevent cancer. However, there comes a point where the risk of the procedure, and the chance of death from other disease is high enough to outweigh the benefit of surveillance. Our work shows that the severity of other diseases in an individual patient is more important than age in identifying the time to stop surveillance.”

In the U.S., endoscopic eradication therapy is recommended for patients with dysplasia, but endoscopic surveillance is indicated for those with NDBE who are at lower risk. The suggested interval between examinations is from three to five years. However, the authors say, there “is no recommendation for the age to discontinue surveillance.”

Continuation at older ages may not be cost-effective, they observe. The potential harm of endoscopic surveillance, such as complications and false-positive results, in concert with advancing age and lower life expectancy due to comorbidities may increase the cost of the surveillance program considerably.

“Evaluating the harms and benefits of many different stop ages in a clinical study,” they say, “would both be very costly and very time consuming.” Instead, the researchers used three independently developed simulation models of esophageal-adenocarcinoma screening and surveillance to simulate patients diagnosed with NDBE, varying in age, sex, and comorbidity level.

All patients were assumed to have had regular surveillance until their current age. The team then calculated incremental costs and quality-adjusted life-years (QALYs) gained from one additional endoscopic surveillance. This was found to be strongly dependent on age, sex and comorbidity.

The optimal age to end surveillance was deemed to be that at which the incremental cost-effectiveness ratio of one more surveillance was just below the willingness-to-pay threshold of $100,000 per QALY.

In men, surveillance at the age of 68 years was considered cost-effective for all comorbidity levels. An additional surveillance at age 74 for those with severe comorbidities was not cost-effective, and at age 86, one more surveillance was not cost-effective for any level of comorbidity.

In men without comorbidities, 81 years was considered the optimal age of last surveillance.

The optimal ages of last surveillance were lower in women than in men, at 75 years in those without comorbidities. For women with severe comorbidity, the optimal stopping age was 69 years and for both moderate and severe comorbidities, it was 73 years.

The researchers conclude, “In addition to chronological age, the comorbidity status and sex of patients are important factors to inform the decision to discontinue surveillance.”

SOURCE: Gastroenterology, online May 8, 2021.

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