Cost-Effectiveness of Risk-Stratified Endoscopic Screening for Esophageal Cancer in High-Risk Areas of China: A Modeling Study

Abstract

Background: Risk-stratified endoscopic screening (RSES), which provides endoscopies to individuals at high risk for esophageal cancer (EC), has been suggested to improve screening efficiency. We aimed to assess the cost-effectiveness of RSES and identify the optimal thresholds for EC screening in high-risk areas of China. Methods: From a healthcare system perspective, a Markov model was constructed to compare the cost-effectiveness of 13 RSES strategies (under different threshold scores of EC risk), universal endoscopic screening strategy, and no screening. Six cohorts of 100 000 women and men with different start ages (40, 45, 50, 55, 60 and 65 years) with follow-up to age 77 years. The incremental cost-effectiveness ratio (ICER), i.e., the incremental cost per quality-adjusted life-years (QALYs) gained, was the primary outcome. Univariate and probabilistic sensitivity analyses were conducted. Findings: Compared with no screening, as the score threshold of the RSES was lowered, additionally gained QALYs increased, with 49−172 QALYs and 329−1258 QALYs gained from 40 years to 65 years. RSES in all age scenarios had ICERs less than 1×GDP per capita (US$10 276/QALY), and 11 RSES strategies with threshold scores of 3–13 had lower ICERs than universal endoscopic screening. Compared to universal endoscopic screening, which had the largest health gains than no screening, RSES with threshold scores of 8, 9, and 10 decreased cost by US$ 0‧35 0–47 million and reduced endoscopies by 7692–9943 with a slight decrease in QALYs. At a willingness-to-pay threshold of US$10 276/QALY, RSES (with threshold scores of 8 and 9) and universal endoscopic screening had a 43‧8–51‧7% and a 49‧6–67‧5% probability of being the most cost-effective at the age of <55 years and ≥ 55 years. Interpretation: RSES is cost-effective in high-risk areas of China. RSES with threshold scores of 8 would be recommended if EC screening was considered for residents aged 40–69 in high-risk areas of China. Funding Information: This work was supported by the Key Technologies Research and Development Program in China (2018YFC1313100), the National High-tech Research and Development Program (grant number: 201502001), the Beijing Science and Technology Planning Project [grant number: J200017], and the Sanming Project of Medicine in Shenzhen (grant number: SZSM201911015). Declaration of Interests: We declare that all authors have no conflicts of interest or financial interests to disclose.