Cost-Effectiveness Analysis of Full-Thickness Resection Device for Small Gastric Subepithelial Tumors

Aims As prevalence of subepithelial tumor (SET) has steadily increased and new minimally-invasive resection techniques have emerged, the choice of surveillance versus removal poses dilemma for both patients and gastroenterologists. Full-Thickness Resection Device (FTRD) is a novel method that allows safe and effective removal of small SET in upper gastrointestinal tract. As international guidelines remain ambiguous on the management of small gastric SET, this study aims to evaluate the cost-effectiveness of FTRD for managing small gastric SET≤2 cm compared with the standard endoscopic surveillance.

Methods A provider’s perspective cost-utility analysis was performed using a decision tree combined with the Markov model. The study population is patients with gastric SET≤2 cm. Quality-adjusted life year (QALY) and event probabilities used in the model were gathered, prioritizing the Asian population from the literature. The cost was estimated by The Comptroller General's Department. Assuming the most prevalent diagnosis of gastric SET is GIST, three therapeutic approaches were analyzed, including (i) FTRD; (ii) Endoscopic biopsy at the time of diagnosis, and (iii) Conventional endoscopic surveillance for tumor progression. The incremental cost-effectiveness ratio (ICER) of 160,000 Baht (4,500 USD) and 100,000 USD per QALY based on Thailand’s and US willingness-to-pay threshold were used to determine the cost-effective scenario. One-way sensitivity analyses were performed to explore the uncertainties and identify scenarios where FTRD is cost-effective.

Results Based on Thailand’s willingness-to-pay threshold, FTRD was cost-effective for patients aged 55 and below. In individuals between the ages of 60 and 65, EUS-guided biopsy at the time of diagnosis to determine the necessity of surveillance was a cost-effective approach. However, for patients aged 70 years and older, neither intervention was cost-effective and surveillance is recommended. From a US perspective where cost of endoscopic procedure is much higher, FTRD was cost-effective in all scenarios, and the intervention was strongly dominant.

Conclusions Endoscopic resection using FTRD is a cost-effective strategy for managing small gastric SET and could be practically applied to both Thai and US population younger than 55 years old with a small gastric SET of unknown histology due to the need for longer duration for surveillance in this age group. The burden of not knowing definite diagnosis may outweigh the additional cost of FTRD thus the option of resection and biopsy should be individualized. [1] [2] [3] [4] [5]

Conflicts of interest

Authors do not have any conflict of interest to disclose.

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Publication History

Article published online:
15 April 2024