Endoscopic Surveillance of Intestinal Metaplasia of the Esophagogastric Junction: A Decision Modeling Analysis

• Published in: The American journal of gastroenterology Vol. 119; no. 7; pp. 1289 - 1297
• Main Authors: Yoon, Ji Yoon, Lim, Francesca, Shah, Shailja C, Rubenstein, Joel H, Abrams, Julian A, Katzka, David, Inadomi, John, Kim, Michelle K, Hur, Chin
• Format: Journal Article
• Language: English
• Published: United States Wolters Kluwer Health Medical Research, Lippincott Williams & Wilkins 01.07.2024
• Subjects: Biopsy; Calibration; Cancer; Costs; Endoscopy; Esophagus; Mortality; Pathology; Patients; Surgery; Surveillance; United States > US; China
• ISSN: 0002-9270; 1572-0241; 1572-0241
• DOI: 10.14309/ajg.0000000000002672

The incidence of esophagogastric junction adenocarcinoma (EGJAC) has been rising. Intestinal metaplasia of the esophagogastric junction (EGJIM) is a common finding in gastroesophageal reflux (irregular Z-line), and may represent an early step in the development of EGJAC in the West. Worldwide, EGJIM may represent progression along the Correa cascade triggered by Helicobacter pylori. We sought to evaluate the cost-effectiveness of endoscopic surveillance of EGJIM. We developed a decision-analytic model to compare endoscopic surveillance strategies for 50-year-old patients after diagnosis of non-dysplastic EGJIM; (1) no surveillance (standard of care), (2) endoscopy every 3 years, (3) every 5 years, or (4) one-time endoscopy at 3 years. We modeled four progression scenarios to reflect uncertainty: A (0.01% annual cancer incidence), B (0.05%), C (0.12%), D (0.22%). Cost-effectiveness of endoscopic surveillance depended on the progression rate of EGJIM to cancer. In the lowest progression rate (scenario A, 0.01%), no surveillance strategies were cost-effective. In moderate progression scenarios, one-time surveillance at 3 years was cost-effective, at $30,989 and $16,526 per QALY for scenarios B (0.05%) and C (0.12%), respectively. For scenario D (0.22%), surveillance every 5 years was cost-effective at $77,695 per QALY.Discussion:Endoscopic surveillance is costly and can cause harm, however, low-intensity longitudinal surveillance (every 5 years) is cost-effective in populations with higher EGJAC incidence. No surveillance or one-time endoscopic surveillance of patients with EGJIM was cost-effective in low-incidence populations. Future studies to better understand the natural history of EGJIM, identify risk factors for progression, and inform appropriate surveillance strategies are required.