Global review of COVID-19 mitigation strategies and their impact on cancer service disruptions.

During the COVID-19 pandemic, countries adopted mitigation strategies to reduce disruptions to cancer services. We reviewed their implementation across health system functions and their impact on cancer diagnosis and care during the pandemic. A systematic search was performed using terms related to cancer and COVID-19. Included studies reported on individuals with cancer or cancer care services, focusing on strategies/programs aimed to reduce delays and disruptions. Extracted data were grouped into four functions (governance, financing, service delivery, and resource generation) and sub-functions of the health system performance assessment framework. We included 30 studies from 16 countries involving 192,233 patients with cancer. Multiple mitigation approaches were implemented, predominantly affecting sub-functions of service delivery to control COVID-19 infection via the suspension of non-urgent cancer care, modified treatment guidelines, and increased telemedicine use in routine cancer care delivery. Resource generation was mainly ensured through adequate workforce supply. However, less emphasis on monitoring or assessing the effectiveness and financing of these strategies was observed. Seventeen studies suggested improved service uptake after mitigation implementation, yet the resulting impact on cancer diagnosis and care has not been established. This review emphasizes the importance of developing effective mitigation strategies across all health system (sub)functions to minimize cancer care service disruptions during crises. Deficiencies were observed in health service delivery (to ensure equity), governance (to monitor and evaluate the implementation of mitigation strategies), and financing. In the wake of future emergencies, implementation research studies that include pre-prepared protocols will be essential to assess mitigation impact across cancer care services.

Skin in the game: The cost consequences of skin cancer diagnosis, treatment and care in Northern Ireland.

BACKGROUND: Skin cancer is a prevalent cancer in the UK. Its rising incidence and mortality rates are expected to result in substantial financial implications, particularly on diagnostic and treatment services for skin cancer management in Northern Ireland (NI). Such anticipated disease increases underscore the need for prevention and control measures that should help guide policymaking and planning efforts. METHODS: We conducted a cost of illness study to assess the economic impact of skin cancer in NI from the healthcare system's perspective, using a bottom-up method, employing NHS reference costs (UK£) for skin cancer diagnosis and treatment patient pathways in 2021/22. Sensitivity analyses varied diagnostic volumes by applying multipliers for benign cases, assuming a diagnostic conversion rate of 6.8%, and examined an alternative chemotherapy regimen compliance rate of 75%. Additionally, proportional cost increases were projected based on future estimated increases of 9% and 28% to malignant melanoma (MM) cases for diagnostic, treatment, and follow-up volumes. RESULTS: Significant numbers of non-melanoma skin cancers (NMSC) and MM cases were recorded, 4289 NMSCs and 439 MM cases. The total cost for managing NMSC was £ 3,365,350. Total costs for MM skin cancer were £ 13,740,681, including £ 8,753,494 for procurement, administration, and chemotherapy drug use. Overall healthcare spending on skin cancer care totalled £ 21,167,651. Sensitivity analysis suggested diagnostic cost may increase significantly to £ 12,374,478 based on referral volume assumptions. If base case rates rise by 9 or 28% estimated total costs of treating skin cancer will increase to £ 22.3 million and £ 24.9 million, respectively. CONCLUSIONS: Skin cancer management costs in NI totalled ∼£ 21.1 million to £ 32.1 million, depending on diagnostic referral assumptions. Costs have risen ∼10-fold over the past decade for MM due largely to chemotherapy costs. A predicted 28% increase in MM cases by 2040 would lead to ∼£ 3.8 million of additional expenditures, providing a significant challenge for cancer health systems.

A Systematic Review of Cost-Effectiveness Analyses of Colorectal Cancer Screening in Europe: Have Studies Included Optimal Screening Intensities?

OBJECTIVE: To assess the range of strategies analysed in European cost-effectiveness analyses (CEAs) of colorectal cancer (CRC) screening with respect to the screening intervals, age ranges and test cut-offs used to define positivity, to examine how this might influence what strategies are found to be optimal, and compare them with the current screening policies with a focus on the screening interval. METHODS: We searched PubMed, Web of Science and Scopus for peer-reviewed, model-based CEAs of CRC screening. We included studies on average-risk European populations using the guaiac faecal occult blood test (gFOBT) or faecal immunochemical test (FIT). We adapted Drummond's ten-point checklist to appraise study quality. RESULTS: We included 39 studies that met the inclusion criteria. Biennial screening was the most frequently used interval which was analysed in 37 studies. Annual screening was assessed in 13 studies, all of which found it optimally cost-effective. Despite this, 25 of 26 European stool-based programmes use biennial screening. Many CEAs did not vary the age range, but the 14 that did generally found broader ranges optimal. Only 11 studies considered alternative FIT cut-offs, 9 of which found lower cut-offs superior. Conflicts between current policy and CEA evidence are less clear regarding age ranges and cut-offs. CONCLUSIONS: The existing CEA evidence indicates that the widely adopted biennial frequency of stool-based testing in Europe is suboptimal. It is likely that many more lives could be saved throughout Europe if programmes could be offered with more intensive annual screening.

Cost consequences of unscheduled emergency admissions in cancer patients in the last year of life.

OBJECTIVES: Cancer is a leading cause of death. This paper examines the utilisation of unscheduled emergency end-of-life healthcare and estimates expenditure in this domain. We explore care patterns and quantify the likely benefits from service reconfigurations which may influence rates of hospital admission and deaths. METHODS: Using prevalence-based retrospective data from the Northern Ireland General Registrar's Office linked by cancer diagnosis to Patient Administration episode data for unscheduled emergency care (1st January 2014 to 31st December 2015), we estimate unscheduled-emergency-care costs in the last year of life. We model potential resources released by reductions in length-of-stay for cancer patients. Linear regression examined patient characteristics affecting length of stay. RESULTS: A total of 3134 cancer patients used 60,746 days of unscheduled emergency care (average 19.5 days). Of these, 48.9% had ≥1 admission during their last 28 days of life. Total estimated cost was £28,684,261, averaging £9200 per person. Lung cancer patients had the highest proportion of admissions (23.2%, mean length of stay = 17.9 days, mean cost=£7224). The highest service use and total cost was in those diagnosed at stage IV (38.4%), who required 22,099 days of care, costing £9,629,014. Palliative care support, identified in 25.5% of patients, contributed £1,322,328. A 3-day reduction in the mean length of stay with a 10% reduction in admissions, could reduce costs by £7.37 million. Regression analyses explained 41% of length-of-stay variability. CONCLUSIONS: The cost burden from unscheduled care use in the last year of life of cancer patients is significant. Opportunities to prioritise service reconfiguration for high-costing users emphasized lung and colorectal cancers as offering the greatest potential to influence outcomes.

A comparison of international modelling methods to evaluate health economics of colorectal cancer screening: a systematic review protocol.

BACKGROUND: Colorectal cancer (CRC) is becoming an increasing health problem worldwide. However, with the help of screening, early diagnosis can reduce incidence and mortality rates. To elevate the economic burden that CRC can cause, cost-effectiveness analysis (CEA) can assist healthcare systems to make screening programmes more cost-effective and prolong survival for early-stage CRC patients. This review aims to identify different CEA modelling methods used internationally to evaluate health economics of CRC screening. METHODS: This review will systematically search electronic databases which include MEDLINE, EMBASE, Web of Science and Scopus. The Preferred Reporting Items for Systematic Reviews and Meta-Analysis (PRISMA) guidance recommendations will design the review, and the Consolidated Health Economic Evaluation Reporting Standards (CHEERS) statement will be used to extract relevant data from studies retrieved. Two reviewers will screen through the evidence using the PICOS (Participant, Intervention, Comparators, Outcomes, Study Design) framework, with a third reviewer to settle any disagreements. Once data extraction and quality assessment are complete, the results will be presented qualitatively and tabulated using the CHEERS checklist. DISCUSSION: The results obtained from the systematic review will highlight how different CRC screening programmes around the world utilise and incorporate health economic modelling methods to be more cost-effective. This information can help modellers develop CEA models which can be adapted to suit the specific screening programmes that they are evaluating. SYSTEMATIC REVIEW REGISTRATION: PROSPERO CRD42022296113.

Spend less to achieve more: Economic analysis of intermittent versus continuous cetuximab in KRAS wild-type patients with metastatic colorectal cancer.

BACKGROUND: In 2014, the COIN-B clinical trial demonstrated that intermittent cetuximab (IC) was a safe alternative to continuous cetuximab (CC), with less cytotoxic chemotherapy, in first-line treatment for KRAS wild-type metastatic colorectal cancer (mCRC). Cetuximab has been available for this indication in England since 2015, but treatment breaks beyond 6 weeks were prohibited, despite real-world evidence that therapy de-escalation maintains equivalent disease control, but with superior Quality-of-Life (QoL). We performed health economic analyses of IC versus CC and used this evidence to help underpin policy change and guide clinical practice through reduction in unnecessary treatment for mCRC patients. METHODS: Employing cost-minimization analysis, we conducted partitioned survival modelling (PSM) and Markov Chain Monte-Carlo (MCMC) simulation to determine costs and quality-adjusted-life-years for IC versus CC. RESULTS: IC reduced costs by £â€¯35,763 (PSM; p < 0.001) or £â€¯30,189 (MCMC) per patient annually, while preserving treatment efficacy and enhancing QoL. Extrapolating to all mCRC patients eligible for cetuximab therapy would have generated cost savings of ~£â€¯1.2 billion over this cohort's lifetime. These data helped underpin a request to NHS England to remove treatment break restrictions in first-line mCRC therapy, which has been adopted as an interim treatment option policy in colorectal cancer during the Covid-19 pandemic. CONCLUSIONS: Our results highlight substantial cost savings achievable by treatment de-escalation, while also reinforcing the importance of therapy breaks to potentially increase tumour responsiveness and reduce treatment toxicity. Our study also highlights how health economic evidence can influence health policy, championing reduced treatment intensity approaches without compromising patient outcomes, which is of particular relevance when addressing the reduced capacity and treatment backlogs experienced during the pandemic.

Colorectal Cancer Screening within Colonoscopy Capacity Constraints: Can FIT-Based Programs Save More Lives by Trading off More Sensitive Test Cutoffs against Longer Screening Intervals?

Introduction. Colorectal cancer (CRC) prevention programs using fecal immunochemical testing (FIT) in screening rely on colonoscopy for secondary and surveillance testing. Colonoscopy capacity is an important constraint. Some European programs lack sufficient capacity to provide optimal screening intensity regarding age ranges, intervals, and FIT cutoffs. It is currently unclear how to optimize programs within colonoscopy capacity constraints. Design. Microsimulation modeling, using the MISCAN-Colon model, was used to determine if more effective CRC screening programs can be identified within constrained colonoscopy capacity. A total of 525 strategies were modeled and compared, varying 3 key screening parameters: screening intervals, age ranges, and FIT cutoffs, including previously unevaluated 4- and 5-year screening intervals (using a lifetime horizon and 100% adherence). Results were compared with the policy decisions taken in Ireland to provide CRC screening within available colonoscopy capacity. Outcomes estimated net costs, quality-adjusted life-years (QALYs), and required colonoscopies. The optimal strategies within finite colonoscopy capacity constraints were identified. Results. Combining a reduced FIT cutoff of 10 µg Hb/g, an extended screening interval of 4 y and an age range of 60-72 y requires 6% fewer colonoscopies, reduces net costs by 23% while preventing 15% more CRC deaths and saving 16% more QALYs relative to a strategy (FIT 40 µg Hb/g, 2-yearly, 60-70 year) approximating current policy. Conclusion. Previously overlooked longer screening intervals may optimize cancer prevention with finite colonoscopy capacity constraints. Changes could save lives, reduce costs, and relieve colonoscopy capacity pressures. These findings are relevant to CRC screening programs across Europe that employ FIT-based testing, which face colonoscopy capacity constraints.

The economic burden of colorectal cancer across Europe: a population-based cost-of-illness study.

BACKGROUND: Colorectal cancer is one of the leading causes of cancer morbidity and mortality in Europe. We aimed to ascertain the economic burden of colorectal cancer across Europe using a population-based cost-of-illness approach. METHODS: In this population-based cost-of-illness study, we obtained 2015 activity and costing data for colorectal cancer in 33 European countries (EUR-33) from global and national sources. Country-specific aggregate data were acquired for health-care, mortality, morbidity, and informal care costs. We calculated primary, outpatient, emergency, and hospital care, and systemic anti-cancer therapy (SACT) costs, as well as the costs of premature death, temporary and permanent absence from work, and unpaid informal care due to colorectal cancer. Colorectal cancer health-care costs per case were compared with colorectal cancer survival and colorectal cancer personnel, equipment, and resources across EUR-33 using univariable and multivariable regression. We also compared hospital care and SACT costs against 2009 data for the 27 EU countries. FINDINGS: The economic burden of colorectal cancer across Europe in 2015 was €19·1 billion. The total non-health-care cost of €11·6 billion (60·6% of total economic burden) consisted of loss of productivity due to disability (€6·3 billion [33·0%]), premature death (€3·0 billion [15·9%]), and opportunity costs for informal carers (€2·2 billion [11·6%]). The €7·5 billion (39·4% of total economic burden) of direct health-care costs consisted of hospital care (€3·3 billion [43·4%] of health-care costs), SACT (€1·9 billion [25·6%]), and outpatient care (€1·3 billion [17·7%]), primary care (€0·7 billion [9·3%]), and emergency care (€0·3 billion [3·9%]). The mean cost for managing a patient with colorectal cancer varied widely between countries (€259-36 295). Hospital-care costs as a proportion of health-care costs varied considerably (24·1-84·8%), with a decrease of 21·2% from 2009 to 2015 in the EU. Overall, hospital care was the largest proportion (43·4%) of health-care expenditure, but pharmaceutical expenditure was far higher than hospital-care expenditure in some countries. Countries with similar gross domestic product per capita had widely varying health-care costs. In the EU, overall expenditure on pharmaceuticals increased by 213·7% from 2009 to 2015. INTERPRETATION: Although the data analysed include non-homogenous sources from some countries and should be interpreted with caution, this study is the most comprehensive analysis to date of the economic burden of colorectal cancer in Europe. Overall spend on health care in some countries did not seem to correspond with patient outcomes. Spending on improving outcomes must be appropriately matched to the challenges in each country, to ensure tangible benefits. Our results have major implications for guiding policy and improving outcomes for this common malignancy. FUNDING: Department for Employment and Learning of Northern Ireland, Medical Research Council, Cancer Research UK, Health Data Research UK, and DATA-CAN.

Prioritisation by FIT to mitigate the impact of delays in the 2-week wait colorectal cancer referral pathway during the COVID-19 pandemic: a UK modelling study.

OBJECTIVE: To evaluate the impact of faecal immunochemical testing (FIT) prioritisation to mitigate the impact of delays in the colorectal cancer (CRC) urgent diagnostic (2-week-wait (2WW)) pathway consequent from the COVID-19 pandemic. DESIGN: We modelled the reduction in CRC survival and life years lost resultant from per-patient delays of 2-6 months in the 2WW pathway. We stratified by age group, individual-level benefit in CRC survival versus age-specific nosocomial COVID-19-related fatality per referred patient undergoing colonoscopy. We modelled mitigation strategies using thresholds of FIT triage of 2, 10 and 150 µg Hb/g to prioritise 2WW referrals for colonoscopy. To construct the underlying models, we employed 10-year net CRC survival for England 2008-2017, 2WW pathway CRC case and referral volumes and per-day-delay HRs generated from observational studies of diagnosis-to-treatment interval. RESULTS: Delay of 2/4/6 months across all 11 266 patients with CRC diagnosed per typical year via the 2WW pathway were estimated to result in 653/1419/2250 attributable deaths and loss of 9214/20 315/32 799 life years. Risk-benefit from urgent investigatory referral is particularly sensitive to nosocomial COVID-19 rates for patients aged >60. Prioritisation out of delay for the 18% of symptomatic referrals with FIT >10 µg Hb/g would avoid 89% of these deaths attributable to presentational/diagnostic delay while reducing immediate requirement for colonoscopy by >80%. CONCLUSIONS: Delays in the pathway to CRC diagnosis and treatment have potential to cause significant mortality and loss of life years. FIT triage of symptomatic patients in primary care could streamline access to colonoscopy, reduce delays for true-positive CRC cases and reduce nosocomial COVID-19 mortality in older true-negative 2WW referrals. However, this strategy offers benefit only in short-term rationalisation of limited endoscopy services: the appreciable false-negative rate of FIT in symptomatic patients means most colonoscopies will still be required.

Patient Preferences in Surveillance: Findings From a Discrete Choice Experiment in the "My Follow-Up" Study.

OBJECTIVES: Approximately 800 000 people die globally from colorectal cancer (CRC) every year. Prevention programs promote early detection, but for people with precancerous lesions, tailoring surveillance to include lifestyle-change programs could enhance prevention potential and improve outcomes. METHODS: Those with intermediate or high-risk polyps removed during CRC screening colonoscopy within the Northern Ireland CRC Screening Programme were invited to complete 8 discrete choice questions about tailored surveillance, analyzed using random-parameters logit and a latent class modeling approach. RESULTS: A total of 231 participants (77% male) self-reported comorbid hypertension (53%), high cholesterol (48%), and mean body mass index of 28.7 (overweight). Although 39% of participants were unaware of their CRC risk status, 30.9% indicated they were already making changes to reduce their risk. Although all respondents were significantly risk- and cost-averse, the latent class analysis identified 3 segments (classes): 1. Class 1 (26.8%) significantly favored phone or email support for a lifestyle change, a 17-month testing interval, and noninvasive testing. 2. Class 2 (48.4%) preferred the status quo. 3. Class 3 (24.7%) significantly favored further risk reduction and invasive testing. CONCLUSIONS: This is the first documented preference study focusing on postpolypectomy surveillance offering lifestyle interventions. Although current care is strongly preferred, risk and cost aversion are important for participants. Latent class analysis shows that some respondents are willing to change diet and lifestyle behaviors, reflecting a teachable moment, with opportunities to personalize and optimize surveillance. Significant discordance between perceived and known risk of recurrence and limited recall of risk information provided within current practice suggest necessary improvements to surveillance programs.

Effect of delays in the 2-week-wait cancer referral pathway during the COVID-19 pandemic on cancer survival in the UK: a modelling study.

BACKGROUND: During the COVID-19 lockdown, referrals via the 2-week-wait urgent pathway for suspected cancer in England, UK, are reported to have decreased by up to 84%. We aimed to examine the impact of different scenarios of lockdown-accumulated backlog in cancer referrals on cancer survival, and the impact on survival per referred patient due to delayed referral versus risk of death from nosocomial infection with severe acute respiratory syndrome coronavirus 2. METHODS: In this modelling study, we used age-stratified and stage-stratified 10-year cancer survival estimates for patients in England, UK, for 20 common tumour types diagnosed in 2008-17 at age 30 years and older from Public Health England. We also used data for cancer diagnoses made via the 2-week-wait referral pathway in 2013-16 from the Cancer Waiting Times system from NHS Digital. We applied per-day hazard ratios (HRs) for cancer progression that we generated from observational studies of delay to treatment. We quantified the annual numbers of cancers at stage I-III diagnosed via the 2-week-wait pathway using 2-week-wait age-specific and stage-specific breakdowns. From these numbers, we estimated the aggregate number of lives and life-years lost in England for per-patient delays of 1-6 months in presentation, diagnosis, or cancer treatment, or a combination of these. We assessed three scenarios of a 3-month period of lockdown during which 25%, 50%, and 75% of the normal monthly volumes of symptomatic patients delayed their presentation until after lockdown. Using referral-to-diagnosis conversion rates and COVID-19 case-fatality rates, we also estimated the survival increment per patient referred. FINDINGS: Across England in 2013-16, an average of 6281 patients with stage I-III cancer were diagnosed via the 2-week-wait pathway per month, of whom 1691 (27%) would be predicted to die within 10 years from their disease. Delays in presentation via the 2-week-wait pathway over a 3-month lockdown period (with an average presentational delay of 2 months per patient) would result in 181 additional lives and 3316 life-years lost as a result of a backlog of referrals of 25%, 361 additional lives and 6632 life-years lost for a 50% backlog of referrals, and 542 additional lives and 9948 life-years lost for a 75% backlog in referrals. Compared with all diagnostics for the backlog being done in month 1 after lockdown, additional capacity across months 1-3 would result in 90 additional lives and 1662 live-years lost due to diagnostic delays for the 25% backlog scenario, 183 additional lives and 3362 life-years lost under the 50% backlog scenario, and 276 additional lives and 5075 life-years lost under the 75% backlog scenario. However, a delay in additional diagnostic capacity with provision spread across months 3-8 after lockdown would result in 401 additional lives and 7332 life-years lost due to diagnostic delays under the 25% backlog scenario, 811 additional lives and 14 873 life-years lost under the 50% backlog scenario, and 1231 additional lives and 22 635 life-years lost under the 75% backlog scenario. A 2-month delay in 2-week-wait investigatory referrals results in an estimated loss of between 0·0 and 0·7 life-years per referred patient, depending on age and tumour type. INTERPRETATION: Prompt provision of additional capacity to address the backlog of diagnostics will minimise deaths as a result of diagnostic delays that could add to those predicted due to expected presentational delays. Prioritisation of patient groups for whom delay would result in most life-years lost warrants consideration as an option for mitigating the aggregate burden of mortality in patients with cancer. FUNDING: None.

Association of Video Game Use With Body Mass Index and Other Energy-Balance Behaviors in Children.

Importance: Childhood obesity is one of the biggest public health threats facing the UK, and video game use is considered a risk behavior for obesity among children. However, few studies have explored the prospective association between video game use and body mass index (BMI) or the potential mediators of this association. Objectives: To investigate whether a longer-term association exists between video game use at a young age and BMI SD score in later years, independent of television use, and to ascertain whether this association is mediated by other energy-balance behaviors. Design, Setting, and Participants: This cohort study is a secondary analysis of data from the Millennium Cohort Study, a nationally representative sample of children who were born in the UK between September 1, 2000, and January 31, 2002, that focused on data collected when the children were aged 5, 7, 11, and 14 years. Data for all variables, except BMI, were provided by parental or caregiver reporting if the children were younger than 14 years of age. At age 14 years, the children self-reported their own behavior. Initial data analysis was conducted between September 18, 2018, and September 28, 2018, with supplementary analyses conducted from October 7, 2019, to November 22, 2019. Main Outcomes and Measures: The main outcome variable was BMI SD scores, with video game use as the exposure variable of interest. Physical activity, bedtime regularity, sugar-sweetened beverage consumption, and high-calorie food consumption were included as potential mediating behaviors. Results: The full sample comprised 16 376 children and had a nearly equal number of boys (8393 [51.3%]) and girls (7983 [48.7%]). Every 1 SD increase in the number of hours of video game use at age 5 years was associated with a ß = 0.018 higher BMI SD score at age 14 years (95% CI, 0.004-0.032). A small partial mediation of this association was found (direct association: ß = 0.017 [95% CI, 0.003-0.031]; indirect association: ß = 0.0011 [95% CI, 0.0003-0.0019]), suggesting that irregular bedtimes and higher consumption of sugar-sweetened beverages were mediators. The mediation model accounted for 36.7% (95% CI, 35.5-37.8) of the variance of the BMI SD score at age 14 years. Conclusions and Relevance: Results of this study suggest a small (and not clinically meaningful) association between video game use in early childhood and higher BMI in later years, which may be mediated by irregular bedtimes and higher consumption of sugar-sweetened beverages. Future interventions to prevent childhood obesity should incorporate health promotion in mainstream video games to target children most at risk because of their high level of video game use.

The Untapped Potential of the Gaming Community: Narrative Review.

BACKGROUND: Video gamers are a population at heightened risk of developing obesity due to the sedentary nature of gaming, increased energy intake, and the disruption caused to their sleep. This increases their risk of developing a number of noncommunicable diseases. To date, research seeking to improve health behaviors has focused on developing novel video games to promote behavior change. Although positive results have emerged from this research, large-scale success has been limited due to the lack of transferability to mainstream games and the focus on children and adolescents. The gaming community has a number of unique aspects, which have received comparatively less attention than the development of new video games. OBJECTIVE: The purpose of this paper is to highlight under-researched areas that have the potential to encourage positive health behavior among this community. METHODS: A narrative review of the lay and academic literature was conducted to provide context and support to our claims that further research could be beneficial in this area. RESULTS: Research has found that advertising can have implicit effects on an individual's memories, which could influence later decisions. However, the effect of the exponential growth of in-game advertisements and the brand sponsorship of gaming events and professional gamers have not been explored in the gaming community. The possibility of using advertising techniques to encourage positive health behaviors within games or at these events has also not been explored. Research suggests that virtual communities can be effective at disseminating health information, but the efficacy of this needs to be explored using known community influencers within the gaming community. CONCLUSIONS: This paper has highlighted a number of potential avenues for the development of interventions within the gaming community. Further research must be conducted alongside game developers to ensure that any in-game developed interventions do not deter gameplay and gamers to ensure that potential approaches are acceptable.

Evaluation of the Effectiveness and Cost-Effectiveness of Personalized Surveillance After Colorectal Adenomatous Polypectomy.

Lifetime risk of developing colorectal cancer is 5%, and 5-year survival at early stage is 92%. Individuals with precancerous lesions removed at primary screening are typically recommended surveillance colonoscopy. Because greater benefits are anticipated for those with higher risk of colorectal cancer, scope for risk-specific surveillance recommendations exists. This review assesses published cost-effectiveness estimates of postpolypectomy surveillance to consider the potential for personalized recommendations by risk group. Meta-analyses of incidence of advanced neoplasia postpolypectomy for low-risk cases were comparable to those without adenoma, with both rates under the lifetime risk of 5%. This group may not benefit from intensive surveillance, which risks unnecessary harm and inefficient use of often scarce colonoscopy capacity. Therefore, greater personalization through deintensified strategies for low-risk individuals could be beneficial. The potential for noninvasive testing, such as fecal immunochemical tests, combined with primary prevention or chemoprevention may reserve colonoscopy for targeted use in personalized risk-stratified surveillance. This review appraised evidence supporting a program of personalized surveillance in patients with colorectal adenoma according to risk group and compared the effectiveness of surveillance colonoscopy with alternative prevention strategies. It assessed trade-offs among costs, benefits, and adverse effects that must be considered in a decision to adopt or reject personalized surveillance.