The practice and cost-effectiveness of opportunistic endoscopic screening for upper gastrointestinal tract cancer: a real-world study in China

Background: The organized endoscopic screening (OrES) for upper gastrointestinal tract cancer (UGTC) in high-risk areas in China has been proven to be cost-effective. However, considering the limitations of applicable regions and populations for OrES, the feasibility of conducting such screenings on a broader scale remains uncertain. To address this gap, we conducted a large-scale, hospital-based real-world study on opportunistic endoscopic screening (OpES) strategy since 2019. We aimed to detail the implementation of the OpES program and evaluate its cost-effectiveness based on 5-year clinical data. Methods: We recruited 1025 hospitals from 710 districts/counties to participate in OpES program during 2019-2023. The endoscopic specialists and pathologists participating in the program were mandated to take annual training programs to acquire the fundamentals of screening techniques. Adult patients who underwent endoscopic examinations were screened for UGTC regardless of their presenting complaint. Patients diagnosed with high-grade intraepithelial neoplasia (HGIN), carcinoma in situ (CIS) and cancer in esophagus or/and stomach were defined as positive screening cases. Patients with HGIN and CIS were defined as early cases. For economic evaluation, we constructed a microsimulation model using parameters obtained directly from the OpES program to evaluate the cost-effectiveness of OpES. The incremental cost-effectiveness ratio (ICER) and quality adjusted life-years (QALY) were measured. Findings: After data cleaning 7,184,735 patients participated in OpES program during 2019-2023. The overall detection rate (DR) and early diagnosis rate (EDR) across all sites were 2.31% and 19.78%. The DRs and EDRs were 1.01% and 23.19% in esophagus, and were 1.35% and 17.81% in stomach. The DR was higher among male patients, and was increasing with age. The EDR was higher among female patients, peaking in the age group of 60-64 years. The DR and EDR were higher in hospitals that consecutively participated in the program for 5 years. Compared to no screening, conducting opportunity screening once per lifetime (ICER: 11512.12 $ per QALY, QALYs saved: 456.49) was cost-effective. The most economically viable strategy was to implement opportunity screening with a starting age of 50 and an ending age of 74 (ICER: 8924.74 $ per QALY, QALYs saved: 358.95). Interpretation: OpES program exhibits significant feasibility and holds potential for cost-effective. Our results can provide evidence and recommendations for opportunistic endoscopic screening guidelines for upper gastrointestinal tract cancer in broader regions of China.