J Korean Med Sci.  2025 Feb;40(6):e43. 10.3346/jkms.2025.40.e43.

Cost Utility Analysis of National Cancer Screening Program for Gastric Cancer in Korea: A Markov Model Analysis

• Bae S
• Lee H
• Her EY
• Lee K
• Kim JS
• Ahn J
• Choi IJ
• Jun JK
• Choi KS
• Suh M

• KMID: 2565169
• DOI: http://doi.org/10.3346/jkms.2025.40.e43

Abstract

Background
The Korean National Cancer Screening Program (NCSP) for gastric cancer requires economic evaluation due to the low sensitivity of upper gastrointestinal series (UGIs) and the associated low cancer survival rate. This study aimed to ascertain the most cost-effective strategy for the NCSP.
Methods
The hypothetical target population of this study was aged 40 years or older, and no actual participants were involved. Markov simulation models were constructed for 25 strategies, combinations of 1) screening methods (UGIs or endoscopy vs. endoscopy-only), 2) screening intervals (one, two, or three-year), and 3) upper age limit of screening (69, 74, 79 years old, or “no limit”). Costs, utility, and other input parameters were extracted from various databases and previous studies. Cost-utility, sensitivity, and scenario analyses were conducted.
Results
The endoscopy-only strategy with a three-year interval with an upper age limit of 69 was the most cost-effective strategy with an incremental cost-utility ratio of KRW 13,354,106 per quality-adjusted life years. According to the probabilistic sensitivity analysis, the uncertainty of the result was significantly small. Scenario analysis is showed that as the screening rate increased, the endoscopy-only strategy saved more costs compared to the current NCSP. Therefore, it is important to maintain a high screening rate when altering the NCSP strategy.
Conclusion
Endoscopy-only screening was more cost-effective method than UGIs for the NCSP. Furthermore, a three-year interval with an upper-age limit of 69 years was the most cost-effective strategy. Efforts to improve cost-effective screening guidelines will support the efficient use of medical resources. Additionally, maintaining a higher screening rate may maximize the impact of the modification in strategy on cost-effectiveness.

Keyword

Incremental Cost-Utility Ratio; Endoscopy; Sensitivity and Scenario Analysis; Gastrointestinal Cancer

Figure

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  Fig. 1 Natural history of gastric cancer.No Ca = No cancer, L = Local cancer, R = Regional cancer, D = Distant cancer, F/U 1–5 = Follow up for 1–5 years.

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  Fig. 2 One-way sensitivity for No screening vs. S9 – Tornado diagram. The red bar indicates when the variable increases, and the blue for decreases. For example, as endoscopy screening cost increases, the ICUR between “no screening” and S9 also increases.ICUR = incremental cost-utility ratio, ENDO = endoscopy, Utility (localized) = utilities for local cancer patients, U_general = utilities for general population, Preval_Dysplasia = prevalent rate of dysplasia, Cost(sEndo) = endoscopy screening cost, Tp_dysplasia2LocalCa = transition rate from dysplasia to local cancer, Sx_Precancer = symptom rate of precancer, P_sEndo_sen = sensitivity of endoscopy screening, Sx_LC = symptom rates for local cancer, Progression rate (L2R) = transition rate from local cancer to regional cancer.This diagram was created using Tree-Age PRO Healthcare version 2020.

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  Fig. 3 Probabilistic sensitivity analysis–acceptability curve.WTP = willingness-to-pay, ENDO = endoscopy.The curves were created using Tree-Age PRO Healthcare version 2020.

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  Fig. 4 Scenario analysis according to proportion of selecting UGIs. The steepness of the slope of the line connecting each point is the ICUR values between each strategy. All slopes have similar steepness.QALY = quality adjusted life years, ENDO = endoscopy, UGI = upper gastrointestinal series, ICUR = incremental cost-utility ratio.

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  Fig. 5 Scenario analysis according to screening rates (current NCSP vs. S9). The slopes of the dotted lines are the ICURs between two connected strategies with the same screening rate.QALY = quality adjusted life year, NCSP = national cancer screening program, ENDO = endoscopy, ICUR = incremental cost-utility ratio, UGI = upper gastrointestinal series.

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