COST-EFFECTIVENESS OF SPONGE-BASED SURVEILLANCE WITH GENETIC TESTING FOR EARLY DIAGNOSIS OF ESOPHAGEAL ADENOCARCINOMA

Saturday, January 9, 2016: 11:30
Kai Chong Tong Auditorium, G/F (Jockey Club School of Public Health and Primary Care Building at Prince of Wales Hospital)

Hla Hla Thein, MD, MPH, PhD, Dalla Lana School of Public Health, University of Toronto, Toronto, Canada, Toronto, ON, Canada, Ayaz Hyder, PhD, Ohio State University, Columbus, OH, Norman Marcon, MD, FRCP(C), Department of Medicine, University of Toronto, Toronto, ON, Canada, Tony Godfrey, PhD, School of Medicine, Boston University, Boston, MA and Lincoln Stein, MD, PhD, Ontario Institute for Cancer Research, Toronto, ON, Canada
Purpose: Incidence rates of esophageal adenocarcinoma (EAC) have increased in Canada over the past three decades. Early diagnosis of Barrett’s esophagus (BE), which is a risk factor for developing EAC, may lead early interventions for better clinical outcomes. This study compared health benefits and cost-effectiveness of current (endoscopy+biopsy) and alternative (sponge-based cytological sampling with genetic testing) surveillance strategies to detect early stage of BE and EAC.

Method(s): We developed a microsimulation model to track individual-level health trajectories accounting for demographic and lifestyle risk factors for developing BE, medication use, screening and surveillance for BE and treatment algorithms for each stage of BE and EAC. Model calibration and validation was performed under the assumption of endoscopy+biopsy surveillance strategy. We compared clinical outcomes, including differences in EAC incidence rate, the number of new EAC cases averted and the number of surveillance procedures per patient-year for BE patients before diagnosis of EAC under two surveillance strategies and used cost-utility analysis to estimate lifetime costs (2014 Canadian dollars), health benefits (quality-adjusted life years, QALYs), and incremental cost-effectiveness ratios. In addition, we undertook extensive sensitivity analysis and value-of-information analysis to determine the expected value of perfect information (EVPI) at different willingness-to-pay values. 

Result(s): Compared to endoscopy+biopsy, sponge-based surveillance with genetic testing reduced overall EAC incidence by 71% and new EAC cases by 26%. Total incremental costs and health benefits (discounted at 5% annually) for sponge-based surveillance with genetic testing under 100% uptake and 11% higher sensitivity than the endoscopy+biopsy strategy for detecting BE with dysplasia were $186,152,124 and 556,511 QALYs gained with a corresponding ICER with 95% confidence interval of $334($307-$366) per QALY gained. Our results were sensitive to parameters related to sensitivity, cost and uptake of sponge-based surveillance with genetic testing.

Conclusion(s): Based on our model, sponge-based surveillance with genetic testing is cost-effective and may reduce incidence of EAC if it is widely taken up in clinical practice. Our results provide novel insights for clinicians, patients, and decision-makers evaluating non-endoscopic surveillance methods in the BE population. These insights should be helpful in designing optimal strategies to reduce the burden of BE and EAC among individuals, health care systems and society.

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