Background Cancer screening is a cornerstone of effective cancer prevention. The 2022 European Council Recommendation on cancer screening encourages risk-based approaches, including risk stratification, when appropriate, to improve the balance of screening benefits, harms, and resource use. To address conceptual heterogeneity and fragmented guidance across cancer sites and countries, the EUCanScreen Joint Action convened a multidisciplinary working group from 22 European countries to develop a shared conceptual framework for risk-stratified cancer screening, as a specific operational approach. Methods We conducted a scoping review to identify definitions, key outcomes, benefits and harms, and ethical considerations relevant to risk-stratified screening. The findings informed a structured brainstorming session and a two-round Delphi survey among EUCanScreen participants. A consultation phase and plenary discussion were used to finalize the framework in May 2025. Results The core elements defining risk-stratified screening are (1) the availability of validated information to estimate individual risk (i.e., the different probability of disease or its natural history), (2) the definition of stratification criteria (i.e., risk thresholds defining groups with similar risk that can be managed similarly), and (3) the presence of evidence-based stratum-specific management protocols.The framework clarifies how risk stratification can be applied across the screening pathway, from eligibility and screening intensity to referral and follow-up. Crosscutting organizational and ethical, legal, and social considerations were identified, including data governance, privacy and data protection, management of genetic information, psychological impacts, equity and access, and training and communication needs.ConclusionsThis collaborative, consensus-based framework identifies essential elements and crosscutting issues for designing, implementing, monitoring, and evaluating risk-stratified cancer screening. The rationale of risk-stratified screening is to modulate screening intensity in both directions, intensifying it for those at higher risk and reducing it for those at lower risk.

IntroductionHealth-economic evidence comparing home treatment (HT) and inpatient treatment (IT) in child and adolescent psychiatry is scarce. This study assessed the cost-effectiveness of both interventions for children and adolescents in acute psychiatric crises using a decision analysis.MethodsWe developed a Markov state-transition model to evaluate the cost-effectiveness of HT compared to IT in children and adolescents with an acute psychiatric crisis, over a 3-year time horizon from a German healthcare provider perspective. Evaluated outcomes included quality-adjusted life years (QALYs) gained, total costs, and the incremental cost-utility ratio (ICUR; in Euro per QALY). Transition probabilities and utility values were obtained from the published literature. Direct medical and direct non-medical costs for IT were derived from German reference data published by the Institute for the Hospital Remuneration System (InEK). Costs for HT were estimated using micro-costing based on the German ward-equivalent treatment model (Stationsäquivalente Behandlung, StäB). Costs and effects were discounted at 3% annually. One-way and probabilistic sensitivity analyses assessed the robustness of the base-case analysis results. Results were reported in accordance with the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) 2022 checklist.ResultsHT was associated with lower discounted costs (61,213 €) and slightly fewer discounted QALYs (1.801 QALYs) compared to IT (total costs: 93,737 € and 1.807 QALYs). Moving from HT to IT was associated with 0.006 QALYs gained and resulted in an ICUR of 5,417,376 €/QALY gained. Results were robust in sensitivity analyses over a wide range of parameter variation.DiscussionThis cost-utility analysis suggests that HT may be a cost-effective alternative to IT in children and adolescents with acute psychiatric crises in Germany, primarily driven by substantial cost savings during the acute phase. However, due to limited and heterogeneous clinical data, results should be interpreted cautiously. Future randomized studies with longer follow-up and child and disease-specific quality-of-life measures are needed to validate these findings.

This study, funded by the EUREGIO-EFH project, aims to evaluate the long-term health impacts of a community-based intervention (CBI) to prevent overweight and obesity among children in Austria, as compared to no intervention. We developed a state-transition decision-analytic model (DAM) for obesity to evaluate the lifetime health outcomes, including quality-adjusted life years (QALY) and life years (LY), of a selected CBI in comparison to no intervention for a hypothetical cohort of 8-year-old children in Austria. Input parameters were derived from the published literature. Sensitivity analyses for various parameters were performed to examine the robustness of the results. In the base-case analysis, the CBI provided a lifetime gain of 0.041 LYs and 0.169 QALYs per individual versus no intervention. In sensitivity analyses, the outcomes were most sensitive to the intervention effect. The results suggest that the CBI improves quality-adjusted life expectancy and slightly increases life expectancy compared to no intervention. Policy implications The developed DAM may be used to compare alternative strategies aimed at preventing overweight and obesity to aid policy makers in evidence-based healthcare decisions in the EUREGIO regions.

Cervical cancer screening programs are established in most upper middle- and high-income countries (UMICs and HICs), yet many eligible women remain underscreened or unscreened. Human papillomavirus (HPV) testing by self-sampling (HPV-SS) has the potential to increase participation rates. In this study, we aim to systematically assess and synthesize the current evidence on cost-effectiveness of implementing HPV-SS in established cervical cancer screening programs in UMICs and HICs. We searched relevant databases (until 02/2024) for studies on the cost-effectiveness of HPV-SS in cervical cancer screening in UMICs and HICs. Following PRISMA guidelines, we included empirical and decision-analytic modelling studies published in English or German reporting health-economic outcomes that can be expressed as incremental cost-effectiveness ratios (ICER). We extracted key study characteristics (e.g. target population, study type) and outcomes (e.g. ICER) and summarized them in systematic evidence tables. Costs were converted to 2024 Euro for cross-country comparison. Of 612 studies, 25 studies met inclusion criteria: 16 model-based cost-effectiveness evaluations and nine economic evaluations along trials. Studies were mainly conducted in HICs. HPV-SS was compared with standard care (e.g. clinician-collected conventional cytology, Pap smear, HPV-testing) or no screening. Eight studies assessed HPV-SS for all screening-eligible women, while 17 studies focused on women not attending regular screening. ICERs were reported in stepwise incremental fashion (i.e. comparing non-dominated strategy to the next non-dominated strategy) in 13 studies, and reported comparing each strategy to a reference each in ten studies. Overall HPV-SS was reported to be cost-effective or cost-saving compared to no screening or standard of care in all but one study. In non-attendees, ICERs ranged from being cost-saving for primary HPV screening with offering HPV-SS vs. not offering HPV-SS (Netherlands) to 60,000 Euro/LYG for a combined strategy (Pap smear until age 35 followed by 5-yearly HPV-SS until age 60) vs. no screening (Sweden). HPV-SS was shown to increase screening participation in studies evaluating screening attendance. Based on our results, HPV-SS can be a practical, feasible and cost-effective approach to increase screening coverage. CRD42024499233.

Background/Objectives: To inform policy making for the German breast cancer (BC) screening program, we systematically evaluated the long-term benefits and harms of extended age limits compared to the current standard of biennial mammography at ages 50–69 years using a decision-analytic approach. Methods: We developed and applied a Markov state-transition model for mammography screening in Germany to systematically assess the benefit–harm trade-offs of various screening strategies varying in age at start and end of screening as well as in screening frequency. The model was populated with international data for sensitivity and specificity of mammography along with German epidemiological, clinical and age-specific quality-of-life data. In deterministic analyses, the following outcomes were projected: detected ductal carcinoma in situ (DCIS) and invasive BC, BC-related deaths, life years (LY), and quality-adjusted life years (QALY), number of positive, false-positive, and total mammograms, overdiagnosis, and the incremental harm–benefit ratio (IHBR). Results: In the base-case analysis, mammography at ages 45–79 (annual, age 45–49; biennial, 50–79) achieved the highest gain in LY (10.0 life years gained [LYG] per 100 women) compared with current screening. Biennial mammography at ages 45–74 resulted in the highest benefits considering both life expectancy and quality of life (3.5 QALYs gained/100 women). Compared to current biennial mammography screening at ages 50–69, lowering the start age from 50 to 45 years resulted in an IHBR of 47 additional mammograms/LYG. Compared to biennial mammography at ages 45–69, biennial mammography at age 45–74 results in 96 additional mammograms/LYG. Further extended screening results in substantially less favorable IHBRs. Conclusions: Based on our results, extending biennial mammography screening to women aged 45 to 74 years may prevent additional BC deaths and increase remaining life expectancy at an acceptable benefit–harm ratio, and improve quality-adjusted life expectancy.

Background/Objectives: In Germany, one third of screening-eligible women remain un- or under-screened. We evaluated the long-term benefits, risks, and cost-effectiveness of human papillomavirus self-sampling (HPV-SS) strategies for non-attendees. Methods: Using a validated Markov-state-transition model, we evaluated HPV-SS for non-attendees every five years at ages 25-65, 30-65 or 35-65, with ordering an HPV-SS test (opt-in), or the test sent with the invitation letter (send-to-all). German clinical, epidemiological, and economic data along with international test-accuracy and HPV-SS-attendance data were used. Outcomes included life-years gained (LYG), the incremental harm-benefit ratio (IHBR), and cost-effectiveness ratio (ICER), compared to the next non-dominated strategy. We adopted the German statutory health insurance perspective with 3% annual discount rate for health effects and costs. Comprehensive sensitivity analyses were performed. Results: Incremental undiscounted effectiveness per 1,000 women compared to standard screening without HPV-SS ranged from 0.90 LYG for 5-yearly HPV-SS (opt-in) at age 35-65 to 1.67 LYG for HPV-SS (send-to-all) at age 25-65. Discounted ICERs compared to next effective non-dominated strategies were 22,700 EUR/LYG for 5-yearly HPV-SS (opt-in) at age 35-65, and for HPV-SS (send-to-all) 25,900 EUR/LYG at age 35-65, 726,000 EUR/LYG at age 30-65, and 1.78 million EUR/LYG at age 25-65. IHBRs for these strategies were 31, 32, 769, and 1,774 additional positive screening tests per LYG, respectively. Results were robust over a wide range of variations in parameters. Conclusions: Offering HPV-SS (send-to-all) to non-attendees every five years at age 35-65may have a good benefit-harm balance and be cost-effective. Our results may inform decision makers and clinical guideline developers in Germany.

PURPOSE:Children and adolescents experiencing psychiatric crises often undergo inpatient treatment, which may limit family involvement, stigmatize young individuals, and impede the application of therapeutic outcomes in their daily lives. This situation can result in increased rates of rehospitalization, the development of chronic conditions, and prolonged hospital stays. Home-based treatment represents a potential alternative to traditional inpatient care. The objective of the planned systematic review is to provide a comprehensive comparison of the effectiveness and cost-effectiveness of inpatient and home-based treatment modalities, with a particular focus on primary outcome parameters such as psychopathology, family functioning, and social functioning. Furthermore, secondary outcomes, including rates of relapses and rehospitalizations, will be evaluated. METHODS:The systematic search will be conducted using Medline, Embase, PsycInfo and Cochrane databases, following the guidelines of the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). The included studies will undergo a rigorous quality assessment using the Cochrane Risk of Bias (RoB2) tool for randomized trials and the Risk of Bias in Non-randomized Studies - of Interventions (ROBINS-I) tool for non-randomized studies. Where appropriate, data will be synthesized by meta-analysis using R-Studio and supplemented by sensitivity analyses to assess the robustness of the results. The overall quality of the evidence is assessed using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. DISCUSSION:The planned systematic literature review will provide a synthesis of the current state of research on the comparative effectiveness of both treatment modalities. The objective is to furnish information for the delivery of effective patient care that also represents a cost-efficient solution for the healthcare system. SYSTEMATIC REVIEW REGISTRATION:This review protocol has been registered with the International Prospective Register of Systematic Reviews (PROSPERO) under the registration number CRD42023458888.

White light (conventional) colonoscopy (WLC) is widely used for colorectal cancer screening, diagnosis and surveillance but endoscopists may fail to detect adenomas. Our goal was to assess and synthesize overall and subgroup-specific adenoma miss rates (AMR) of WLC in daily practice. We conducted a systematic review in MEDLINE, EMBASE, Cochrane Library, and grey literature on studies evaluating diagnostic WLC accuracy in tandem studies with novel-colonoscopic technologies (NCT) in subjects undergoing screening, diagnostic or surveillance colonoscopy. Information on study design, AMR overall and specific for adenoma size, histology, location, morphology and further outcomes were extracted and reported in standardized evidence tables. Study quality was assessed using the QUADAS-2 tool. Random-effects meta-analyses and meta-regression were performed to estimate pooled estimates for AMR with 95

Background This study includes the long-term benefit-harm analysis of population-wide colorectal cancer (CRC) screening strategies commissioned by the Austrian National Committee for Cancer Screening (ANCCS). In addition, we present the related cost-effectiveness analysis. Methods Using a validated decision-analytic Markov state transition model, we evaluated 17 by the ANCCS suggested CRC-screening strategies differing in tests (fecal-immunochemical test (FIT), guaiac-based fecal occult blood test (gFOBT), colonoscopy (COL)), age at start (40,45,50 years) and end (COL: 65,70,75 years, FIT/gFOBT 75 years), and intervals (2,5,10 years). Positive FIT/gFOBT tests are followed by colonoscopy. Evaluated outcomes included health benefits (life-years gained (LYG), CRC-cases/CRC-deaths avoided), harms (severe colonoscopy complications, psychological harms due to positive test results (PTR), additional colonoscopies), stepwise evaluated incremental harm-benefit ratios (IHBR), and incremental cost-effectiveness ratios (ICER). We applied the Austrian healthcare system perspective, a lifelong-time horizon and conducted sensitivity analyses. Results The most effective colonoscopy-based screening strategy is colonoscopy at age 40/50/60/70 (449 LYG per 1000 individuals) with an IHBR of 3 PTR/LYG compared to COL45/55/65 (ICER: 13,032 Euro/LYG vs. COL45/55/65/75). The most effective fecal blood-test-based strategy is annual FIT testing starting at age 40 years (488 LYG per 1000 individuals) and an IHBR of 30 PTR/LYG compared to FIT40+2y (biennial FIT starting age 40). All biennial FIT-based screening strategies represent alternative options on the harm-benefit efficiency frontier with IHBR of PTR/LYG: 2 (FIT50+2y vs. no screening), 5 (FIT45+2y vs. FIT50+2y), and 7 (FIT40+2y vs. FIT45+2y). The cost-effectiveness analyses provided stepwise ICERs ranging from 3391 Euro/LYG (FIT45+2y vs. FIT50+2y) to 47,812 Euro/LYG (FIT40+1y vs. FIT40+2y). Conclusions Our decision analysis shows benefit-harm and cost-effectiveness trade-offs. In the consensus meeting of the ANCCS, colonoscopy- and FIT-based screening starting at age 45 were selected as suggested screening strategies, accounting for benefit-harm balance, evidence level, and implementation aspects.

BackgroundIt is still a matter of debate whether a reduction in cancer-specific mortality due to cancer screening fully translates into a reduction in all-cause mortality and thus into a gain in life expectancy. Nevertheless, decision-analytic models simulating the health consequences of screening compared with no screening predict substantial gains in life expectancy.PurposeThe aim of this review was to systematically assess methodological competing mortality risk features that affect the translation of cancer-specific mortality reductions into gains in life expectancy in decision-analytic screening models for prostate, lung, breast, and colorectal cancer.Data SourcesLiterature databases were systematically searched for clinical and economic decision-analytic models evaluating the effect of screening for prostate, lung, breast, and colorectal cancer compared with no screening.Study SelectionForty-two clinical and economic decision-analytic models were included for narrative synthesis.Data ExtractionBasic information and specific methodological features of the included decision-analytic models were extracted using a standardized approach.Data SynthesisCharacteristics and methodological features of the identified studies were summarized in evidence tables.LimitationsThe review focused on models that reported undiscounted outcomes of life-years gained for standard screening strategies.ConclusionsThis review highlights key modeling features related to competing mortality risks that should be considered in decision-analytic models assessing the effects of cancer screening. All included models predicted gains in life expectancy with screening, although the magnitude of these gains varied both within and across cancer types. Models that considered competing mortality risks tended to predict smaller lifetime gains from screening interventions. Future studies should prioritize the use of advanced modeling approaches that account for competing mortality risks to improve the accuracy of benefit-harm assessments in cancer screening.HighlightsThis is the first systematic assessment of methodological competing mortality risk features of decision-analytic screening models across 4 cancer types.Models vary greatly regarding predicted gains in life expectancy, natural history assumptions (onset and progression rates), methodological model features, and screening strategies.Models that considered competing mortality risks or adjusted life expectancy for comorbidities predicted smaller lifetime gains for screening compared with no screening.

IntroductionIn Germany, organized cervical cancer screening with annual Papanicolaou (Pap) cytology for women age 20 to 34 years and three-yearly co-testing with human papillomavirus (HPV) and Pap for women as of age 35 years is standard. However, about 30 percent of women eligible for screening remain un/under-screened. We systematically evaluated benefits, risks, and cost-effectiveness of offering additional HPV self-sampling (HPV-SS) to non-attendees.Methods A validated Markov model for the German context was used to evaluate different HPV-SS screening strategies compared to standard clinician-based screening: HPV-SS for non-attendees age 25 to 65, 30 to 65 or 35 to 65 years, every five years with regular invitation, either opt-in (invitation with link to order the test), or send-to-all (test sent with invitation). German clinical, epidemiological, and economic data (index year 2022/23), along with test accuracy and HPV-SS-attendance data from international meta-analyses and trials were incorporated. Outcomes included undiscounted life years gained (LYG) compared to standard screening without HPV-SS in non-attendees, and the incremental cost-effectiveness ratio (ICER; in EUR/LYG). Comprehensive sensitivity analyses were performed.Results Incremental undiscounted effectiveness (compared to standard screening without HPV-SS) and discounted ICERs (compared to next effective) for non-dominated HPV-SS screening strategies were 0.00090 LYG (EUR22,700/LYG) for offering with five-yearly screening invitation an HPV-SS (opt-in) to non-attendees age 35 to 65, 0.00166 LYG (EUR25,900/LYG) for HPV-SS (send-to-all) age 35 to 65, 0.00167 (EUR726,000/LYG) for HPV-SS (send-to-all) age 30 to 65, and 0.00167 LYG (EUR1.78 million/LYG) for HPV-SS (send-to-all) age 25 to 65 years. Other opt-in strategies were dominated. Results were robust over a wide range of parameter variations.ConclusionsOffering HPV-SS (send-to-all) to non-attendees every five years as an additional strategy within the organized cervical cancer screening program is effective and cost effective in the German context. The results can be used to inform decision-makers and clinical guideline developers regarding incorporation of the specific version of HPV self-sampling into the established organized cervical cancer screening program in Germany.