The Cost-Effectiveness of Gastric Cancer Screening and Surveillance Among Average-Risk and Risk-Stratified...

Guidelines cite certain risk factors for gastric cancer (GC) as an indication for surveillance of incidentally diagnosed gastric intestinal metaplasia (IM); however, guidance on risk thresholds for routine IM screening is lacking. Cost-saving options in average-risk populations, such as bundling endoscopy with colonoscopy for colorectal cancer screening, have not been directly explored. We aimed to assess effectiveness and cost-effectiveness of screening for GC among average-risk and risk-stratified populations.

Markov models of the natural history of GC were developed to compare standalone and bundled screening and surveillance strategies with esophagogastroduodenoscopy (EGD) in average-risk individuals, and individuals risk-stratified based on family history of GC, immigrant status, and race/ethnicity. The primary outcomes were total cost, quality-adjusted life-years gained (QALYGs), and incremental cost-effectiveness ratios (ICERs). Secondary outcomes were GC incidence, mortality, and unadjusted life-years gained.

Screening EGD starting at age 50 with surveillance every 5 years if IM is diagnosed was cost-effective in Asian individuals (ICER, $83,600/QALYG), and starting at age 55 was cost-effective in Black individuals (ICER, $99,500/QALYG), Hispanic individuals (ICER, $78,700/QALYG), those with a family history of GC (ICER, $76,200/QALYG), and high-risk immigrants (ICER, $95,900/QALYG). Standalone EGD screening was not cost-effective in average-risk individuals, but bundling endoscopy with colonoscopy at age 45 with surveillance for IM every 5 years was cost-effective (ICER, $87,000/QALYG).

Targeted screening in high-risk individuals for GC should be considered in the United States. Combining upper and lower endoscopy may make one-time GC screening and risk-stratified surveillance feasible for the general population. Prospective studies are needed to validate potential benefits of preventative interventions.