Cost-effectiveness of regular surveillance versus endoscopy at need for patients with Barrett’s esophagus: Economic evaluation alongside the Barrett’s Oesophagus Surveillance Study (BOSS) randomized controlled trial

Less is more? BOSS Study evaluates endoscopic surveillance in Barrett’s esophagus

To date, the BOSS study (Barrett’s Esophagus Surveillance Study) is the largest and methodologically strongest randomized study to examine whether regular endoscopic surveillance in non-dysplastic Barrett’s esophagus (NDBE) provides clinically relevant benefits. In this multicenter UK study, 3,452 patients from 109 centers were observed over a median period of 12.8 years and randomly assigned to either 2-yearly surveillance endoscopy or a symptom-based “endoscopy at need” strategy. In the surveillance arm, significantly more esophagogastroduodenoscopies (EGD) were performed (6,124 vs. 2,424), and dysplastic changes were detected more frequently. However, no advantages were found for either the primary or secondary clinical endpoints: Overall survival and cancer-specific survival did not differ between the two strategies. There was no significant difference in the incidence of esophageal adenocarcinoma (EAC), and the tumor stage at diagnosis remained comparable. The annual progression rate from NDBE to EAC was only ~0.23% per year, confirming a very low absolute risk. Overall, 19.2% of patients in the surveillance arm and 20.7% in the control arm died, clearly missing the primary endpoint of demonstrating a survival benefit.
Although Barrett’s esophagus is traditionally considered an important risk factor for EAC, the question is also whether the Barrett’s finding alone represents the central risk—or whether other, often overlooked factors deserve greater emphasis. There is growing evidence suggesting that chronic inflammation (GERD), obesity, metabolic factors, biliary reflux exposure, and genetic clonal alterations in the mucosa contribute significantly to cancer development and have greater impact on individual risk than the Barrett’s diagnosis itself. In clinical practice, this means that instead of using Barrett’s status as the sole basis for surveillance decisions, a comprehensive, multifactorial risk assessment should be performed, considering inflammatory burden, lifestyle factors, and molecular markers.
The BOSS study was accompanied by a health economic modeling exercise to evaluate the BOSS data over a period of almost 23 years (12.8 years of follow-up plus 10 years of model projection). The surveillance strategy resulted in significantly higher costs while generating only a minimal increase in quality-adjusted life years (QALYs). The total cost per patient was US$5,309 compared to US$3,182 in the “endoscopy at-need” group, while the additional health benefit was extremely low. The ratio of additional costs to additional benefits is thus well above what is generally considered efficient or acceptable in healthcare systems, demonstrating that close surveillance is not cost-effective under the given assumptions. 
Overall, the clinical and economic analyses convey a consistent message: Routine 2-yearly surveillance endoscopy for NDBE does not improve survival, reduce tumor incidence, or lead to earlier-stage detection, but results in markedly higher endoscopic burden and significantly higher costs, while the absolute risk of progression remains very low.
Given this background, the key question is how the findings of the BOSS study should be translated into clinical practice. The accompanying editorial emphasizes the ethical principle primum non nocere and underscores that the procedural, psychological, and financial burdens associated with routine surveillance are disproportionate to a survival benefit that has not been demonstrated. This is especially true for patients with non-dysplastic Barrett’s esophagus, exhibiting a very low progression rate but relevant competing mortality risks. For these individuals, routine, frequent endoscopic monitoring is difficult to justify.
The data support taking a critical look at current surveillance strategies and applying them in a more nuanced way. For patients with short-segment Barrett’s esophagus, advanced age, limited treatment options, or no additional risk factors, symptom-driven approaches or substantially longer surveillance intervals may be clinically reasonable and ethically appropriate. At the same time, the findings highlight the need for more precise risk stratification: While intensive surveillance has shown no benefit for low-risk patients, uncertainty remains for those with longer Barrett’s segments, confirmed low-grade dysplasia, a family history of the disease, or other risk factors. In these cases, ongoing surveillance and endoscopic therapy remain justified but should be implemented in a structured, quality-controlled, and targeted manner.
In conclusion, the current evidence does not suggest abandoning surveillance altogether. Instead, it supports a shift towards a more individualized, risk-adapted, and resource-conscious approach that fully acknowledges the very low absolute risk of progression and the lack of a survival benefit in many patients.