Cost-utility of comprehensive endoscopic screening strategies for upper gastrointestinal cancer in rural China

Background: Endoscopic screening for upper gastrointestinal cancer (UGC) has been proven to be effective, but there is little evidence of its cost-utility regarding comprehensive screening strategies. We aimed to assess the cost-utility of various endoscopic screening strategies for UGC within the Chinese healthcare system. Methods: A Markov model was constructed to assess the cost-utility of 40 screening strategies consisting of different screening starting ages (40, 45, 50, or 55 years old), screening frequencies (once per lifetime and every year, 2 years, 5 years, 10 years and 15 years), and follow-up or not. Model parameters were estimated based on our survey data, public surveillance data, and published literature. The primary outcome was the incremental cost-utility ratios (ICUR, incremental health care costs per quality-adjusted life-year [QALY] gained). Deterministic and probabilistic sensitivity analyses were performed to examine key parameter uncertainty. Findings: The cost-utility analysis identified 7 strategies as the dominant strategies given 1 times per capita GDP (¥70653/$9821.69) of Shandong province in China in 2019. Compared with no screening, all dominant strategies were associated with improved ICUR by CNY 12 095.60 to ¥31 456.29 per QALY. Compared with neighboring strategy, all dominant strategies were associated with improved ICUR by CNY 12 095.62 to ¥66 764.06 per QALY. The y40-nf-il would be the most cost-utility strategy, with probabilities of 42% to 95% at 1-3 times the per capita GDP. At a WTP lower than 1 times per capita GDP, the probability of the y40-nf-i2 strategy being more cost-utility is highest. Findings were robust in all sensitivity analyses. Interpretation: Combined endoscopic screening for UGC appears cost-utility in the Chinese healthcare system. Screening at the age of 40, conducting it annually and without follow-up, would be the optimal strategy. However, in areas with economic constraints and limited resources, modifying this optimal strategy to be implemented every 2 years could enhance cost-utility. Those findings would be useful for the development of policies targeting the prevention and control of UGC in China.