Cost-effectiveness of treatment and endoscopic surveillance of precancerous lesions to prevent gastric cancer.
BACKGROUND
Although surveillance for Barrett esophagus and other gastrointestinal precancerous conditions is recommended, no analogous guidelines exist for gastric lesions. The objective of this study was to estimate the clinical benefits and cost-effectiveness of treatment and endoscopic surveillance to prevent gastric cancer.


METHODS
The authors developed a state-transition decision model for a cohort of US men with a recent incidental diagnosis of gastric precancerous lesions (dysplasia, intestinal metaplasia, or atrophy). Strategies included 1) no surveillance or treatment and 2) referral for surveillance and treatment, and varied by surveillance frequency (none, every 10 years, every 5 years, or every year) and treatment modality for dysplastic and cancerous lesions (surgery or endoscopic mucosal resection [EMR]). The term "post-treatment surveillance" was restricted to surveillance of individuals after treatment. Data were based on published literature and databases. Outcomes included lifetime gastric cancer risk, quality-adjusted life expectancy, lifetime costs, and incremental cost-effectiveness ratios.


RESULTS
For a cohort of men with dysplasia aged 50 years, the lifetime gastric cancer risk was 5.9%. EMR with annual surveillance reduced the lifetime cancer risk by 90% and cost $39,800 per quality-adjusted life year (QALY). Addition of post-treatment surveillance every 10 years provided little incremental benefit ( approximately 5%) but cost >$1 million per QALY. Results were most sensitive to surgical risks and the proportion of lesions completely removed with EMR. For intestinal metaplasia, surveillance every 10 years reduced lifetime cancer risk by 61% and cost $544,500 per QALY.


CONCLUSIONS
EMR with surveillance every 1 to 5 years for gastric dysplasia was promising for secondary cancer prevention and had a cost-effectiveness ratio that would be considered attractive in the United States. Endoscopic surveillance of less advanced lesions did not appear to be cost-effective, except possibly for immigrants from high-risk countries.
Yeh
Jennifer M
JM
Center for Health Decision Science, Harvard School of Public Health, Boston, MA 02115, USA. jyeh@hsph.harvard.edu
Hur
Chin
C
Kuntz
Karen M
KM
Ezzati
Majid
M
Goldie
Sue J
SJ
D003362:Cost-Benefit Analysis; D055088:Early Detection of Cancer; D004724:Endoscopy / Q000191:economics*; D006801:Humans; D008297:Male; D008875:Middle Aged; D008954:Models, Biological; D011230:Precancerous Conditions / Q000175:diagnosis* / Q000191:economics / Q000628:therapy*; D012680:Sensitivity and Specificity; D013274:Stomach Neoplasms / Q000191:economics* / Q000517:prevention & control*