ABSTRACT Background Barrett's esophagus is the known precursor to esophageal adenocarcinoma (EAC), a cancer with poor prognosis. While endoscopic surveillance detects early dysplasia and prevents progression, most Barrett's esophagus patients do not progress to EAC, leading to invasive and costly surveillance. This study aimed to identify cost‐effective endoscopic surveillance strategies by risk stratifying patients based on Barrett's esophagus segment length and sex. Methods A Markov cohort model was developed to simulate the natural history of Barrett's esophagus to EAC. The model assessed 85 surveillance strategies and varied endoscopy intervals from 2 to 10 years for nondysplastic Barrett's esophagus and 6–12 months for dysplasia. Risk stratification was based on segment length (≤ 2 and ≤ 3 cm) and sex. Costs, utilities and transition probabilities were derived from published literature and clinical databases. Deterministic and probabilistic sensitivity analyses were performed, and cost‐effectiveness was evaluated from a third‐party payer perspective using a threshold of AU50 000/QALY (2023 US dollars 35 945/QALY). Results The most cost‐effective strategy was biennial surveillance for long‐segment BE (> 2 cm) and 12‐month surveillance for LGD, excluding surveillance in low‐risk patients (ICER US23 737/QALY). Risk‐based surveillance consistently outperformed nonstratified strategies. Sensitivity analyses confirmed the robustness of the model, with key drivers being transition rates and endoscopy costs. Conclusion We identified cost‐effective risk‐stratified endoscopic surveillance strategies for Barrett's esophagus, particularly when excluding low‐risk patients. Tailored risk‐guided surveillance strategies could improve resource allocation and clinical outcomes in managing Barrett's esophagus. The conserved resources can then be utilized to identify high‐risk individuals in the community.
Vissapragada et al. (2026) studied this question.