Dysplasia-Stratified Surveillance Identifies Optimal Strategies for Preventing Esophageal Adenocarcinoma in Barrett's Esophagus: An Incidence-Based Cost-Effectiveness Model

The risk of esophageal adenocarcinoma (EAC) in Barretts esophagus (BE) varies substantially by segment length and dysplasia grade. This study evaluated the cost-effectiveness and health impacts of dysplasia-stratified EAC surveillance strategies for the Japanese BE population. A state-transition model was developed comparing endoscopy, sponge test, breath test, and miRNA test with no surveillance from a healthcare payer perspective over a lifetime. Non-invasive strategies were assessed as primary surveillance tools, with positive results triggering confirmatory endoscopy, and a scenario analysis evaluated AI-assisted endoscopy. Five BE populations of 50-year-old individuals were modeled: ultra-short segment BE (USSBE), short-segment BE (SSBE), long-segment nondysplastic BE (LSBE-NDBE), LSBE with low-grade dysplasia (LSBE-LGD), and LSBE with high-grade dysplasia (LSBE-HGD). Each modality was evaluated at surveillance intervals of 1, 2, 3, 4, 5, or 10 years. Primary outcomes included net monetary benefits, costs, quality-adjusted life-years, incremental cost-effectiveness ratios, and EAC deaths, with sensitivity analyses assessing parameter uncertainty. Surveillance was not cost-effective for USSBE, SSBE, or LSBE-NDBE. For LSBE-LGD, annual endoscopy was most cost-effective, averting 83 EAC deaths per 10,000 individuals, while for LSBE-HGD, annual breath testing was most cost-effective, averting 295 deaths. These findings support dysplasia-specific surveillance in LSBE with implications for global surveillance practice.