Guidelines suggest endoscopic screening for esophageal adenocarcinoma (EAC) among individuals with symptoms of gastroesophageal reflux disease (GERD) and additional risk factors. We aimed to determine at what age to perform screening and whether sex and race should influence the decision.
We conducted comparative cost-effectiveness analyses using three independent simulation models. For each combination of sex and race (white/black, 100,000 individuals each), we considered 41 screening strategies, including one time or repeated screening. The optimal strategy was that with the highest effectiveness and an incremental cost-effectiveness ratio less than $100,000 per quality-adjusted life-year gained.
Among white men, 536 EAC deaths were projected without screening, and screening individuals with GERD twice at ages 45 and 60 years was optimal. Screening the entire white male population once at age 55 years was optimal in 26% of probabilistic sensitivity analysis (PSA) runs. Black men had fewer EAC deaths without screening (84), and screening those with GERD once at age 55 years was optimal. Although white women had slightly more EAC deaths (103) than black men, the optimal strategy was no screening, though screening those with GERD once at age 55 years was optimal in 29% of PSA runs. Black women had a very low burden of EAC deaths (29), and no screening was optimal as benefits were very small and some strategies caused net harm.
The optimal strategy of screening differs by race and sex. White men with GERD symptoms can potentially be screened more intensely than currently recommended. Screening women is not cost-effective and may cause net harm for black women.

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