BACKGROUND:Strong evidence highlights that sufficient physical activity (PA) has multiple benefits for people living with and beyond cancer. However, many are not meeting PA recommendations. APPROACH is a trial of a theory-driven, app-based behavioral support intervention to promote brisk walking after breast, prostate, or colorectal cancer. OBJECTIVE:The aim of this trial is to evaluate the efficacy and cost-effectiveness of the intervention. METHODS:APPROACH is a multicenter, phase III, 2-armed, individually randomized controlled trial (N=472). We will recruit patients with localized breast, prostate, or colorectal cancer from hospitals in Yorkshire and surrounding areas in the North of England, United Kingdom, and randomize them 1:1 between the intervention and control arm (usual care). The intervention consists of an app designed for the general population to encourage brisk walking (NHS Active 10), supplemented with habit-based behavioral support, including 2 brief telephone or video calls, a leaflet, website, and walking planners. The primary endpoint is the difference between trial arms in the changes from baseline in activPAL-assessed average minutes of brisk walking (≥100 steps per minute) after 3 months. Demographic and medical characteristics will be collected through self-report and hospital records. Secondary outcomes (assessed at 0, 3, and 6 months) will be the other activPAL-assessed outcomes (brisk walking at 6 months, total steps, light PA, standing time, and sitting times, weekly metabolic equivalent of task), self-reported PA, and self-reported BMI and waist circumference. Patient-reported outcome measures of quality of life, fatigue, sleep, anxiety, depression, self-efficacy, habit strength for walking, and social support will also be collected. Interviews will explore experiences of receiving the intervention. We will use health economic modeling to estimate the cost-effectiveness of the intervention over a lifetime horizon. RESULTS:The study was funded in June 2019. Trial recruitment commenced in November 2023 and is planned to be completed in 2025. As of December 2025, a total of 473 participants have been randomized. The publication of the main results is expected in autumn 2027 after all follow-up data collection and analysis are complete. CONCLUSIONS:Overall findings will determine the clinical and cost-effectiveness of the intervention for patients diagnosed with breast, prostate, or colorectal cancer. If successful, APPROACH provides a potential model of supportive care to increase PA among people living with and beyond cancer. TRIAL REGISTRATION:ISRCTN Registry ISRCTN14149329; https://www.isrctn.com/ISRCTN14149329. INTERNATIONAL REGISTERED REPORT IDENTIFIER (IRRID):DERR1-10.2196/77096.

Background: Past workplace exposure to asbestos in combination with tobacco smoking has increased the risk of lung cancer for some residents in an area within the Friuli Venezia Giulia region, Northeast Italy. In light of studies showing that lung cancer screening (LCS) with low-dose computed tomography (LDCT) can reduce mortality, local stakeholders and decision-makers decided to assess the potential benefits, harms and cost-effectiveness of a single round of LCS with LDCT versus standard care among people aged 55 to 80 who were formerly exposed to asbestos and with at least 10 pack-years of smoking. Methods: An economic model was developed using a decision tree connected to a Markov cohort model. The primary outcome was the incremental cost per additional quality-adjusted life year (QALY). Other outcomes included the number of life years saved, the number of deaths averted and overdiagnosis. Results: Per 10,000 people screened, the intervention led to 395 additional QALYs (95% credible interval: 129 to 831) and incremental total costs of EUR 1,086,345 (95% credible interval: -852,607 to 2,155,826). The incremental cost per QALY gained was EUR 2750. There was a probability of cost-effectiveness of 99.5% relative to a threshold of EUR 25,000. Conclusions: The model estimated that the intervention was cost-effective. The model's simplifications and limitations should be considered when interpreting the findings in relation to policy-making decisions. Further research could include the costs and benefits of incidental findings and could assess the cost-effectiveness of repeated rounds of screening for the same population.

Background: Reducing health inequity is essential. The FAIRSTEPS (Framework to Address Inequities in pRimary care using STakEholder PerspectiveS) study developed and prioritised 28 vignettes describing complex primary care interventions targeted to disadvantaged groups, through Delphi consensus ranking by primary care practitioners for feasibility and perceived usefulness. Aim: To build on FAIRSTEPS by quantifying potential impacts of prioritised vignettes on costeffectiveness and health equity. Design & setting: Simplified distributional costeffectiveness analysis (DCEA) in England. Method: Pragmatic literature searches were carried out around each vignette to identify the following: (1) available economic evidence; and (2) information about size and distribution of populations targeted. Economic evidence was quality assessed using adapted National Institute for Health and Care Excellence (NICE) appraisal checklists. Extracted cost and quality-adjusted life-year (QALY) data and population data, were combined with published distributions of health opportunity costs and baseline lifetime health, to estimate net health benefits and equity measures for each vignette. Results: Suitable costeffectiveness evidence was identified for 17 of 28 vignettes, with variable study quality and applicability. Fourteen vignettes were both costeffective and equity-generating, with the most beneficial on both dimensions relating to community champions for health promotion; integrated care for people sleeping rough, engaged in sex work, or using drugs; and weight-loss programmes targeted at people on low incomes. Conclusion: Simplified DCEA using published data can be used to provide additional evidence to help prioritise complex primary care interventions aimed at disadvantaged populations, although the analysis is hindered by low quality economic data and limited study comparability. Further research estimating baseline health and health opportunity cost distributions across disadvantaged groups would improve accuracy of health equity assessments.

Introduction Breast cancer is a leading cause of cancer-related death among women. Women with lower income, those living in rural areas and women of Black ethnicity are more likely to be diagnosed at advanced stages and have poorer survival outcomes. Reducing these inequities is an important public health priority. This study aimed to identify a cost-effective strategy for reducing breast cancer-related inequities and to evaluate the equity impact of the intervention across population subgroups.Methods We developed a novel individual-level microsimulation model to assess both the equity impact and cost-effectiveness of a community health worker-led education intervention in rural areas. The model, with annual cycles, simulated rural and urban breast cancer populations in South Africa using data from national and regional cancer datasets and followed individuals over a lifetime horizon. Costs were estimated from the provider perspective and outcomes included life-years, quality-adjusted life-years (QALYs), and incremental cost-effectiveness ratios (ICERs) compared with three willingness-to-pay thresholds (ZAR 58 018/ZAR 109 468/ZAR 328 408). Parameter uncertainty was explored using probabilistic sensitivity analysis. Equity impact was evaluated by estimating changes in age-standardised all-cause mortality across subgroups defined by place of residence (rural vs urban) and ethnicity (Black vs non-Black), using both absolute (rate differences) and relative (rate ratios) measures.Results The intervention generated average gains of 0.35 life-years and 0.31 QALYs per patient across the breast cancer population. Inequities by residence decreased, with an absolute reduction of 229.65 per 1000 patients with breast cancer in the age-standardised mortality rate difference, and a relative reduction in the rate ratio of 0.80. By ethnicity, absolute and relative reductions of 110.26 per 1000 patients and 0.27, respectively, were observed between Black and non-Black populations. The intervention was cost-effective, with an ICER of ZAR 44 124 (I$6036) per QALY gained, which is below all three willingness-to-pay thresholds considered.Conclusions Community health worker programmes represent a cost-effective strategy to reduce breast cancer-related inequities. Their integration into national cancer control plans in low-income and middle-income countries should be prioritised and supported.

Background:Colorectal cancer is the fourth most common cancer and the second most common cause of cancer deaths in England. Most cases of colorectal cancer arise from a prior adenomatous polyp in the bowel lining. Colonoscopy is the gold standard investigation for people with symptoms suggestive of colorectal cancer. During a colonoscopy, polyps can be removed or a biopsy can be taken. However, waiting times for colonoscopy can be long and the procedure can be unpleasant. Colon capsule endoscopy may provide an alternative diagnostic procedure to rule out polyps or colorectal cancer. Objectives:To evaluate the clinical effectiveness, acceptability and cost-effectiveness of colon capsule endoscopy using PillCam COLON 2 for detecting colorectal polyps and colorectal cancer. Methods and data sources:A systematic review searched six bibliographic databases and eight conference proceedings in August 2024. Studies of PillCam COLON 2 in symptomatic or polyp surveillance patients were included if they were randomised controlled trials, or if they reported data on diagnostic test accuracy, yield or patient preference. Bayesian pooling of sensitivity and specificity was performed. The economic analysis included a review of existing models and development of an independent model to assess the cost-effectiveness of colon capsule endoscopy versus colonoscopy and computed tomography colonography in three main populations (symptomatic patients with a faecal immunochemical test score of 10-100 μg/g, symptomatic faecal immunochemical test < 10 μg/g and surveillance patients). Subgroup analyses were conducted in patients who are able and willing to undergo colonoscopy and those who are not (denoted 'COL-eligible' and 'COL-ineligible'). Results:Among the diagnostic test accuracy studies (11-64% patients 'in-scope'), for polyps of any size (two studies), ≥ 6 mm (four studies) and ≥ 10 mm (four studies), pooled sensitivities were 0.78 (95% credible interval 0.51 to 0.90), 0.83 (95% credible interval 0.70 to 0.91) and 0.85 (95% credible interval 0.70 to 0.94), respectively. Specificities were 0.60 (95% credible interval 0.27 to 0.88), 0.69 (95% credible interval 0.52 to 0.81) and 0.90 (95% credible interval 0.82 to 0.95), respectively. Among yield studies, colonoscopy was spared in 37-50% of symptomatic patients (three studies). Data on colonoscopy spared in surveillance patients were available from one study; however, these data are confidential and cannot be reported here. In patients unwilling/unable to undergo colonoscopy, colon capsule endoscopy completed 70-98% of incomplete colonoscopies. Patient preference studies indicated general satisfaction with PillCam COLON 2, but some conflicting information on patient preference for colon capsule endoscopy compared to colonoscopy and computed tomography colonography. For colonoscopy-eligible patients, within all three main analysis populations, the External Assessment Group's model suggests that colon capsule endoscopy is expected to lead to small quality-adjusted life-year losses and higher costs than colonoscopy; hence, colon capsule endoscopy is dominated by colonoscopy. For colonoscopy-ineligible patients, colon capsule endoscopy either dominated by computed tomography colonography or has an incremental cost-effectiveness ratio which is markedly higher than £30,000 per quality-adjusted life-year gained. Despite these findings, colon capsule endoscopy is predicted to lead to substantial reductions in the number of colonoscopies required, particularly for symptomatic patients who are able to undergo colonoscopy. Limitations:The generalisability of the diagnostic test accuracy data to symptomatic and polyp surveillance patients was unclear. Conclusions:Colon capsule endoscopy is expected to be less effective and more expensive than colonoscopy. However, it could help to free up constrained colonoscopy services, particularly in people with symptoms suggestive of bowel cancer. Study registration:The systematic review protocol is available on the PROSPERO website (registration number CRD42024586405). Funding:This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment programme (NIHR award ref: NIHR136010) and is published in full in Health Technology Assessment; Vol. 30, No. 58. See the NIHR Funding and Awards website for further award information.

Modelling the cost effectiveness of screening interventions presents unique challenges. These relate to a lack of knowledge about underlying health states and disease progression in the absence of screening, added costs arising from incidental findings, screening recall and follow-up diagnostics, imperfect uptake, potential harms to otherwise healthy people, and impacts on resource capacity and equity. No specific but generalisable advice currently exists to help guide health economic modellers working in this area. There is a need for tailored recommendations beyond the widely used, health economic modelling frameworks. We aimed to develop a set of recommendations for modelling the cost effectiveness of screening programmes. In our iterative process, we first drafted a conceptual document outlining key issues requiring recommendations. This framework was then expanded based on additional themes identified through a survey of screening modelling experts. Next, the draft recommendations were shared with a broader international expert group, which included modellers, health economists and policy specialists. Finally, the core concepts were refined and agreed upon during a virtual stakeholder meeting. A set of ten recommendations and a checklist are presented. The document provides guidance on critical methodological requirements for modelling screening interventions. These guidelines are intended to help health economic modellers and screening policy makers working to evaluate screening interventions across a wide range of diseases and jurisdictions with clarity, rigour and consistency.

BACKGROUND:Public health economic modelling is an approach capable of managing the intricacies involved in evaluating interventions without direct observational evidence. It is used to estimate potential long-term health benefits and cost outcomes. The aim of this review was to determine the scope of health economic models in the evaluation of salt and/or alcohol interventions globally, to provide an overview of the literature and the modelling methods and structures used. METHODS:Searches were conducted in Medline, Embase, and EconLit, and complemented with citation searching of key reviews. The searches were conducted between 13/11/2022 and 8/11/2023, with no limits to publication date. We applied a health economic search filter to select model-based economic evaluations of public health policies and interventions related to alcohol consumption, dietary salt intake, or both. Data on the study characteristics, modelling approaches, and the interventions were extracted and synthesised. RESULTS:The search identified 1,958 articles, 82 of which were included. These included comparative risk assessments (29%), multistate lifetables (27%), Markov cohort (22%), microsimulation (13%), and other (9%) modelling methods. The included studies evaluated alcohol and/or salt interventions in a combined total of 64 countries. Policies from the UK (23%) and Australia (18%) were the most frequently evaluated. A total of 58% of the models evaluated salt policies, 38% evaluated alcohol policies, and only three (4% of included modelling studies) evaluated both alcohol- and salt-related policies. The range of diseases modelled covered diabetes and cardiovascular disease-related outcomes, cancers, and alcohol-attributable harm. Systolic blood pressure was a key intermediate risk factor in the excessive salt-to-disease modelling pathway for 40 (83%) of the salt modelling studies. The effects of alcohol consumption on adverse health effects were modelled directly using estimates of the relative risk of alcohol-attributable diseases. CONCLUSIONS:This scoping review highlights the substantial utilisation of health economic modelling for estimating the health and economic impact of interventions targeting salt or alcohol consumption. The limited use of combined alcohol and salt policy models presents a pressing need for models that could explore their integrated risk factor pathways for cost-effectiveness comparisons between salt and alcohol policies to inform primary prevention policymaking.

Objectives This study aims to identify the key factors driving excessive alcohol and salt consumption in Ghana, both of which are modifiable risk factors for diseases such as cardiovascular conditions and cancers. Using the socio-ecological model (SEM), we qualitatively examine stakeholder perspectives to gain a comprehensive understanding of the influences contributing to these unhealthy consumption patterns.Design and methods A qualitative study was conducted using semi-structured interviews. Transcripts were analysed thematically, with identified drivers mapped onto the corresponding levels of influence within the SEM.Participants The study included 21 purposively sampled stakeholders from government and academic institutions in Ghana, including policymakers, practitioners and researchers.Results Drivers of excessive salt and alcohol consumption were identified across all five levels of the SEM. At the intrapersonal level, disregard for health risks was a key factor. Community-level drivers included easy access to unhealthy foods and cultural norms promoting alcohol use at social events and salt in traditional dishes. At the societal and policy levels, inadequate regulation of the alcohol and food industries was found to reinforce lower-level drivers, further encouraging unhealthy consumption.Conclusions This study highlights the multilevel influences on alcohol and salt consumption, emphasising the interactions across SEM levels. It highlights that addressing unhealthy consumption is not solely a matter of personal responsibility, demonstrating that societal and policy factors play a significant role in shaping health and dietary behaviours. The findings underscore the need for comprehensive public health strategies that address influences at multiple levels to effectively reduce excessive alcohol and salt intake.

Introduction:Fecal immunochemical testing (FIT) at a threshold of 10 mg haemaglobin (Hb)/g is used in English primary care to prioritise urgent referral for colorectal cancer (CRC) investigation in symptomatic patients. The COLOFIT algorithm, based on FIT score, age, sex and blood results, performs better than FIT alone for identifying CRC. We assessed the cost-effectiveness of COLOFIT compared with FIT and investigated optimal risk thresholds. Methods:An individual patient-level simulation model was developed, with synthetic populations constructed from data used to validate COLOFIT. Referral criteria based on different FIT scores and COLOFIT-assessed risk thresholds were modelled using probabilistic and scenario analyses. Outcomes included costs, quality-adjusted life years (QALYs) and cost-effectiveness measured using incremental net monetary benefit (INMB) based on a willingness to pay threshold of £20 000/QALY. Results:COLOFIT at a CRC risk threshold of 0.64% has a 98% probability of being more cost-effective than FIT 10 mg Hb/g (INMB is £5.67 per person), while detecting similar numbers of cancers. Cost-effectiveness is achieved by cost savings from reducing referrals outweighing QALYs lost through reorienting expedited CRC diagnoses from younger (<50) to older (≥70) patients. Cost-effectiveness improves as risk thresholds rise. High structural uncertainty around cancer progression during diagnostic delay and diagnosis of other serious bowel diseases considerably affects cost-effectiveness. Conclusions:COLOFIT is likely to be more cost-effective than FIT alone and could help alleviate pressure on diagnostic services. However, strategies to improve diagnosis in the under 50s would be necessary to mitigate potential harm. Further research should assess how COLOFIT impacts cancer survival and diagnosis of other serious bowel diseases.

Testing high-risk populations for non-visible haematuria may enable earlier detection of bladder cancer, potentially decreasing mortality. This research aimed to assess the cost-effectiveness of urine dipstick screening for bladder cancer in high-risk populations in England. A microsimulation model developed in R software was calibrated to national incidence data by age, sex and stage, and validated against mortality data. Individual risk factors included age, sex, smoking status and factory employment. We evaluated three one-time screening scenarios: (1) current and former smokers of different ages within the 55–70 years range, (2) a mixed-age cohort of smokers aged 55–80 years and (3) individuals aged 65–79 years from high-risk regions. Probabilistic and scenario analyses evaluated uncertainty. The incremental cost-effectiveness ratio (ICER) was calculated and compared with the standard £20,000/quality-adjusted life year (QALY) threshold using payer’s perspective and 2022 year of evaluation with 3.5

To analyse whether conducting a randomised controlled trial (RCT) to evaluate an online weight maintenance guided self-help intervention (Supporting Weight Management (SWiM)) would offer good value for money in the United Kingdom. We examined 24 RCT designs by varying inclusion criteria (participants completing behavioural weight management, specialist-led weight management, diabetes prevention programme, type 2 diabetes remission, digital weight management, all weight management services), trial duration (1–2 years), and sample size (n = 500 or 2000). Trial benefits were estimated by the method of expected value of sample information analysis using a health economic model. The model examines how the proposed intervention affects weight maintenance over time (with uncertainty), and generates estimated lifetime Quality Adjusted Life Years (QALYs) and National Health Service (NHS) costs. Structured expert elicitation with 4 experts was undertaken to quantify pre-trial uncertainty in the effectiveness of SWiM compared with usual care. All trial designs were simulated to estimate trial benefits: the reduction in the costs of an inefficient decision for future populations over 10 years. Trial designs offer value for money if trial benefits exceed trial costs. For three inclusion criteria options (groups recently completing ‘diabetes remission’, ‘digital weight management’ or ‘specialist weight management’), the cost of the proposed trials was estimated to exceed the estimated trial benefit (value of the reduction in decision uncertainty) over 10 years. For the other three inclusion criteria options (groups recently completed ‘behavioural weight management’, ‘diabetes prevention programme’, or ‘all weight loss programmes’), 12 trial designs produced greater benefits than costs. The optimal trial design option would include ‘all weight loss programmes’, with 2 years follow-up and sample size n = 2000. Investment in a large RCT to evaluate the SWiM intervention for patients completing a range of weight loss interventions offers the greatest value to the NHS.

BACKGROUND:Low-dose computed tomography (CT) screening for lung cancer is available for high-risk individuals in England. Screening simultaneously for upper abdominal conditions, including cancer, is feasible. Here, we estimate the cost-effectiveness of one-off upper abdominal CT screening, added onto lung cancer screening, based on the Yorkshire Kidney Screening Trial (YKST) feasibility study. METHODS:A multi-disease health economic model was developed. Ten cancers and abdominal aortic aneurysm (AAA) were modelled over a lifetime horizon. YKST data informed disease prevalence, resource use and screening costs. Costs, quality-adjusted life-years (QALYs) and cost-effectiveness were estimated probabilistically. RESULTS:Screening per person costs £70.89, produces 0.0059 QALYs, and has 96% probability of being cost-effective, with an incremental cost-effectiveness ratio of £12,085. AAA contributes most to cost-effectiveness, followed by kidney cancer, but some cancer findings reduce cost-effectiveness. Screening is more cost-effective at younger ages. Screen-detectable disease prevalence, severity and mortality risk contribute most to uncertainty. CONCLUSIONS:One-off upper abdominal CT screening is potentially cost-effective, but costs, harms and benefits vary between conditions. Cost-effectiveness is driven by early diagnosis of AAA, then kidney cancer, illustrating the importance of considering all relevant diseases in screening models. A larger trial would provide more robust data to refine the cost-effectiveness argument. CLINICAL TRIAL REGISTRATION:ClinicalTrials.gov: NCT05005195.

Background Health economic modelling indicates that referral to a behavioural weight management programme is cost saving and generates QALY gains compared with a brief intervention. The aim of this study was to conduct a cross-model validation comparing outcomes from this cost-effectiveness analysis to those of a comparator model, to understand how differences in model structure contribute to outcomes. Methods The outcomes produced by two models, the School for Public Health Research diabetes prevention (SPHR) and Health Checks (HC) models, were compared for three weight-management programme strategies; Weight Watchers (WW) for 12 weeks, WW for 52 weeks, and a brief intervention, and a simulated no intervention scenario. Model inputs were standardised, and iterative adjustments were made to each model to identify drivers of differences in key outcomes. Results The total QALYs estimated by the HC model were higher in all treatment groups than those estimated by the SPHR model, and there was a large difference in incremental QALYs between the models. SPHR simulated greater QALY gains for 12-week WW and 52-week WW relative to the Brief Intervention. Comparisons across socioeconomic groups found a stronger socioeconomic gradient in the SPHR model. Removing the impact of treatment on HbA1c from the SPHR model, running both models only with the conditions that the models have in common and, to a lesser extent, changing the data used to estimate risk factor trajectories, resulted in more consistent model outcomes. Conclusions The key driver of difference between the models was the inclusion of extra evidence-based detail in SPHR on the impacts of treatments on HbA1c. The conclusions were less sensitive to the dataset used to inform the risk factor trajectories. These findings strengthen the original cost-effectiveness analyses of the weight management interventions and provide an increased understanding of what is structurally important in the models.

INTRODUCTION:Increased moderate to vigorous physical activity (MVPA) can improve clinical and psychosocial outcomes for people living with and beyond cancer (LWBC). This study aimed to assess the feasibility and acceptability of trial procedures in a pilot randomised controlled trial (RCT) of a theory-driven app-based intervention with behavioural support focused on promoting brisk walking (a form of MVPA) in people LWBC (APPROACH). METHODS:Participants diagnosed with breast, prostate or colorectal cancer were recruited from a single UK hospital site. Assessments at baseline and 3 months included online questionnaires, device-measured brisk walking (activPAL accelerometer) and self-reported weight and height. Participants were randomised to intervention or control (care as usual). The intervention comprised a non-cancer-specific app to promote brisk walking (National Health Service 'Active 10') augmented with print information about habit formation, a walking planner and two behavioural support telephone calls. Feasibility and acceptability of trial procedures were explored. Initial estimates for physical activity informed a power calculation for a phase III RCT. A preliminary health economics analysis was conducted. RESULTS:Of those medically eligible, 369/577 (64%) were willing to answer further eligibility questions and 90/148 (61%) of those eligible were enrolled. Feasibility outcomes, including retention (97%), assessment completion rates (>86%) and app download rates in the intervention group (96%), suggest that the trial procedures are acceptable and that the intervention is feasible. The phase III RCT will require 472 participants to be randomised. As expected, the preliminary health economic analyses indicate a high level of uncertainty around the cost-effectiveness of the intervention. CONCLUSIONS:This pilot study demonstrates that a large trial of the brisk walking intervention with behavioural support is both feasible and acceptable to people LWBC. The results support progression onto a confirmatory phase III trial to determine the efficacy and cost-effectiveness of the intervention.

BACKGROUND:Breast cancer is the most diagnosed cancer in the world, with a worse prognosis documented in low- and middle-income countries. Inequalities pertaining to breast cancer outcomes are observed at within-country level, with demographics and socioeconomic status as major drivers. AIM:This review aims to aggregate all available evidence from low- and middle-income countries on public health interventions that can be utilized to reduce breast cancer inequalities within the breast cancer continuum. METHODS:The study was a systematic review and narrative synthesis of available literature, with the literature search conducted between September and October 2021. The search was re-run in September 2022 to update the review. PubMed, Scopus, Embase, African Index Medicus and LILACS were searched, based on predetermined criteria. Randomized controlled trials, cohort studies and quasi-experimental studies were included for review, while studies without an intervention and comparator group were excluded. The Joanna Briggs Institute family of checklists was used for quality assessment of the included studies. Data pertaining to study design, quality control and intervention effectiveness was extracted. RESULTS:A total of 915 studies were identified for screening and 21 studies met the selection criteria. Only one study specifically evaluated the impact of an intervention on breast cancer inequalities. Diverse, multi-level interventions that can be utilized to address breast cancer inequalities through targeted application to disadvantaged subpopulations were identified. Educational interventions were found to be effective in improving screening rates, downstaging through early presentation as well as improving time to diagnosis. Interventions aimed at subsidizing or eliminating screening payments resulted in improved screening rates. Patient navigation was highlighted to be effective in improving outcomes throughout the breast cancer continuum. CONCLUSION:Findings from the systematic review underline the importance of early detection in breast cancer management for low- and middle-income countries. This can be achieved through a variety of interventions, including population education, and addressing access barriers to public health services such as screening, particularly among under-served populations. This study provides a comprehensive database of public health interventions relevant to low- and middle-income countries that can be utilized for planning and decision-making purposes. Findings from the review highlight an important research gap in primary studies on interventions aimed at reducing breast cancer inequalities in low- and middle-income countries. SYSTEMATIC REVIEW REGISTRATION:PROSPERO registration number: CRD42021289643.

ABSTRACTContextRisk stratification has been suggested as a strategy for improving cancer screening. Any changes to existing programmes must be acceptable to the public.ObjectiveThis study aimed to explore the preferences and considerations of individuals relating to the introduction of different risk‐based strategies to determine eligibility for colorectal cancer (CRC) screening.Study DesignParticipants completed a discrete choice experiment (DCE) within online interviews. Nine conjoint‐analysis tasks were created, each with two potential CRC screening programmes. The attributes included personal risk of CRC, screening invitation strategy and impact. Participants chose between programmes while thinking aloud and sharing their thoughts. Transcripts were analysed using codebook thematic analysis.ParticipantsTwenty participants based in England aged 40–79 years without previous cancer history or medical expertise.ResultsWhen choosing between programmes, participants first and primarily looked to prioritise saving lives. The harms associated with screening were viewed as a surprise but also felt by most to be inevitable; the benefits frequently outweighed, therefore, harms were considered less important. Risk stratification using individual characteristics was considered a nuanced approach to healthcare, which tended to be preferred over the age‐alone model. Detailed personal risk information could be taken more seriously than non‐personalised information to motivate behaviour change. Although it had minimal impact on decision‐making, not diverting resources for screening from elsewhere was valued. Individuals who chose not to provide health information were considered irresponsible, while it was important that those with no information to provide should not lose out.ConclusionRisk‐stratified CRC screening is generally aligned with public preferences, with decisions between possible stratification strategies dominated by saving lives. Even if attributes including risk factors, risk stratification strategy and risk communication contributed less to the overall decision to select certain programmes, some levels more clearly fulfilled public values; therefore, all these factors should be taken into consideration when redesigning and communicating CRC screening programmes.Patient or Public ContributionThe primary data source for this study is interviews with 20 members of the public (current, past or future CRC screening invitees). Two public representatives contributed to planning this study, particularly the DCE.

Background Population-based cancer screening programmes are shifting away from age and/or sex-based screening criteria towards a risk-stratified approach. Any such changes must be acceptable to the public and communicated effectively. We aimed to explore the social and ethical considerations of implementing risk stratification at three different stages of the bowel cancer screening programme and to understand public requirements for communication. Methods We conducted two pairs of community juries, addressing risk stratification for screening eligibility or thresholds for referral to colonoscopy and screening interval. Using screening test results (where applicable), and lifestyle and genetic risk scores were suggested as potential stratification strategies. After being informed about the topic through a series of presentations and discussions including screening principles, ethical considerations and how risk stratification could be incorporated, participants deliberated over the research questions. They then reported their final verdicts on the acceptability of risk-stratified screening and what information should be shared about their preferred screening strategy. Transcripts were analysed using codebook thematic analysis. Results Risk stratification of bowel cancer screening was acceptable to the informed public. Using data within the current system (age, sex and screening results) was considered an obvious next step and collecting additional data for lifestyle and/or genetic risk assessment was also preferable to age-based screening. Participants acknowledged benefits to individuals and health services, as well as articulating concerns for people with low cancer risk, potential public misconceptions and additional complexity for the system. The need for clear and effective communication about changes to the screening programme and individual risk feedback was highlighted, including making a distinction between information that should be shared with everyone by default and additional details that are available elsewhere. Conclusions From the perspective of public acceptability, risk stratification using current data could be implemented immediately, ahead of more complex strategies. Collecting additional data for lifestyle and/or genetic risk assessment was also considered acceptable but the practicalities of collecting such data and how the programme would be communicated require careful consideration.