1038 Lesser Sensitivity and Positive Predictive Value of Fecal Immunochemical Test (FIT) in Right Advanced Colonic Neoplasia Than Left Lesions

Background: Screening for Barrett's esophagus (BE) and esophageal adenocarcinoma (EAC) with an EGD remains controversial, especially with regards to its cost-effectiveness. Prior models have not considered the added benefits of identifying early gastric cancer (GCA) or esophageal squamous cell cancer (SCC). In addition, screening costs can be reduced by performing screening EGD at the same time as screening colonoscopy. Aim: To evaluate the cost effectiveness of screening the general population for UGI cancers (EAC, esophageal SCC, GCA) by performing an EGD at the time of screening colonoscopy. Methods: A Markov Model was created using a hypothetical cohort of 50 year old patients with no gastrointestinal symptoms who are already undergoing screening colonoscopy. The primary decision compared two strategies: adding and not adding a screening EGD. Options for surveillance for non-dysplastic BE (NDBE) and low grade dysplasia (LGD), non-compliance with surveillance, endoscopic eradication therapy (EET) for BE with high grade dysplasia (HGD) and mucosal EAC, and endoscopic misdiagnosis were included in the model. Transition rates and utility values were taken from the published literature and expert consensus. Costs were viewed from the perspective of a third party payor and were obtained from the Centers for Medicare and Medicaid Services. The time horizon was from age 50 to age 80 or death. The primary outcome was the incremental cost-effectiveness ratio (ICER). Results: Screening the general population at the age of 50 for UGI cancers with surveillance of NDBE and LGD required $113,500 per quality-adjusted life-year (QALY) compared to no screening or surveillance. A screening only strategy (no BE surveillance) was dominated by the screening and surveillance strategy. If all patients were compliant with surveillance guidelines and all patients with HGD and mucosal EAC underwent EET (base case: 55% compliant, 50% choose EET while remaining undergo surgery), the ICER for screening and surveillance decreased to $92,300 per QALY compared to no screening or surveillance. In one-way sensitivity analyses, the prevalence of EAC, esophageal SCC, or GCA would have to increase by a factor of 10.3, 28.7, or 5.8, respectively to generate an ICER of less than $50,000 per QALY. Conclusion: The ICE ratio for screening the general population for UGI cancers with endoscopy remains high, despite accounting for reduced endoscopy costs and the combined benefits of detecting early EAC, esophageal SCC, and GCA. However, the ICER compares favorably to commonly performed screening strategies for other cancers.