The epidemiology of the most frequent cancers in Poland in 2015-2021 and the impact of the COVID-19 pandemic on cancer incidence

BACKGROUND

The late diagnosis, despite the improving availability and accessibility of diagnostic procedures during the last decade in Poland and cooperation between specialist cancer centres, remains an unsolved problem. Moreover, the accessibility to healthcare resources and diagnostic procedures has been drastically reduced because of the COVID-19 pandemic in 2019-2020. The study aimed to present the epidemiology of the most frequent cancers diagnosed in Poland as well as the impact of the COVID-19 pandemic on cancers' incidence.

METHODS

Depersonalized, epidemiological data was obtained from the National Health Fund of Poland. In this retrospective study, the epidemiological analysis was performed and divided into subregions, according to patients' domicile. For each of the subregions, we have calculated the incidence rate per 100,000 standardized to the European Standard Population 2013. The time points of providing the first healthcare service were considered as the time of cancer diagnosis.

RESULTS

In the 2015-2019 period, before the COVID-19 pandemic occurred, the nationwide incidence of analysed cancers remained stable or slightly decreased (as the lung cancer). Simultaneusly, during the same period the prevalence of the prostate cancer has increased and the large differences between subregions with the least and the highest incidence were observed. Subsequently, the incidences of all analyzed cancers decreased in 2020, compared to the period before the COVID-19 pandemic occurred. Then, in 2021 a disproportionate increase in cancers' incidence rates was noted.

CONCLUSIONS

Our results show a significant decrease in the incidence rate of the most frequent cancers diagnosed in Poland in 2020 compared to 2019. Subsequently, in 2021 the increase of the incidence ratios was noted, most likely due to the gradual reduction of epidemic restrictions.

Impact of health disparities on national breast cancer screening participation rates in South Korea

Socioeconomic barriers to cancer screening exist at a regional level. The deprivation index is used to estimate socioeconomic gradients and health disparities across different geographical regions. We aimed to examine the impact of deprivation on breast cancer screening participation rates among South Korean women. Municipal breast cancer screening participation rates in women were extracted from the National Cancer Screening Information System and linked to the Korean version of the deprivation index constructed by the Korea Institute for Health and Social Affairs. A generalised linear mixed model was employed to investigate the association between the deprivation index and age-standardised breast cancer screening participation rates in 2005, 2012, and 2018. Participation rates increased gradually across all age groups from 2005 to 2018. Participants in their 60 s consistently had one of the highest participation rates (2005: 30.37%, 2012: 61.57%, 2018: 65.88%). In 2005, the most deprived quintile had a higher estimate of breast cancer screening participation than the least deprived quintile (2nd quintile; estimate: 1.044, p = 0.242, 3rd quintile; estimate: 1.153, p = 0.192, 4th quintile; estimate: 3.517, p = 0.001, 5th quintile; estimate: 6.913, p =  < 0.0001). In 2012, the participation rate also increased as the level of deprivation increased. There were no statistically meaningful results in 2018. Regions with high deprivation have a higher participation rate in breast cancer screening. The role of health disparities in determining cancer outcomes among women in Korea requires further examination.

Relationship between Health Inequalities and Breast Cancer Survival in Mexican Women

OBJECTIVE

We aimed to analyze the relationship between the survival of patients with breast cancer and health inequalities.

METHODS

A retrospective cohort study of women with stage III breast cancer according to public healthcare was conducted. Groups were stratified according to the course of treatment and the presence of chronic disease other than cancer. Survival functions were estimated by using the Kaplan-Meier estimator, while the Cox proportional hazards model was employed for prognostic assessment.

RESULTS

The study was performed on 964 breast cancer patients. One hundred and seventy-six patients (18.23%) died during the follow-up period and 788 (81.77%) were alive at the end of the follow-up period. Education, marital status, personal history of prior biopsies, and socioeconomic status (SES) were found to be linked with survival. However, only SES exceeded the baseline risk of mortality when the treatment cycle was interrupted (full treatment: unadjusted 4.683, p = 0.001; adjusted 4.888 p = 0.001, partial treatment: unadjusted 1.973, p = 0.012; adjusted 4.185, p = 0.001). The same effect was observed when stratifying by the presence of chronic disease other than cancer (with chronic disease adjusted HR = 4.948, p = 0.001; unadjusted HR = 3.303, p = 0.001; without chronic disease adjusted HR = 4.850, p = 0.001; unadjusted HR = 5.121, p = 0.001).

CONCLUSION

Since lower SES was linked with a worse prognosis, strategies to promote preventive medicine, particularly breast cancer screening programs and prompt diagnosis, are needed.

Socio-economic Inequality of Utilization of Cancer Testing in Europe: A Cross-Sectional Study

There are currently screening programmes for breast, cervical and colorectal cancer in many European countries. However, the uptake of cancer screening in general may vary within and between countries. The aim of this study is to assess the inequalities in testing utilization by socio-economic status and whether the amount of inequality varies across European regions. We conducted an analysis based on cross-sectional data from the second wave of the European Health Interview Survey from 2013 to 2015. We analysed the use of breast, cervical, and colorectal cancer testing by socio-economic position (household income, educational level and employment status), socio-demographic factors, self-perceived health and smoking behaviour, by using multinomial logistic models, and inequality measurement based on the Slope index of inequality (SII) and Relative index of inequality (RII). The results show that the utilization of mammography (Odds Ratio (OR) = 0.55, 95% confidence interval (95%CI):0.50–0.61), cervical smear tests (OR = 0.60, 95%CI:0.56–0.65) and colorectal testing (OR = 0.82, 95%CI:0.78–0.86) was overall less likely among individuals within a low household income compared to a high household income. Also, individuals with a non-EU country of birth, low educational level and being unemployed (or retired) were overall less likely to be tested. The income-based inequality in breast (SII = 0.191;RII = 1.260) and colorectal testing utilization (SII = 0.161;RII = 1.487) was the greatest in Southern Europe. For cervical smears, this inequality was greatest in Eastern Europe (SII = 0.122;RII = 1.195). We concluded that there is considerable inequality in the use of cancer tests in Europe, with inequalities associated with household income, educational level, employment status, and country of birth.

Mortality from cancer in people with severe mental disorders in Emilia Romagna Region, Italy

Objective

To examine cancer‐related mortality in patients with severe mental disorders (SMI) in the Emilia Romagna (ER) Region, Northern Italy, during the period 2008–2017 and compare it with the regional population.

Methods

We used the ER Regional Mental Health Registry identifying all patients aged ≥18 years who had received an ICD‐9CM system diagnosis of SMI (i.e., schizophrenia or other functional psychosis, mania, or bipolar affective disorders) during a 10‐year period (2008–2017). Information on deaths (date and causes of death) were retrieved through the Regional Cause of Death Registry. Comparisons were made with the deaths and cause of deaths of the regional population over the same period.

Results

Amongst 12,385 patients suffering from SMI (64.1% schizophrenia spectrum and 36.9% bipolar spectrum disorders), 24% (range 21%–29%) died of cancer. In comparison with the general regional population, the mortality for cancer was about 50% higher among patients with SMI, irrespective if affected by schizophrenia or bipolar disorders. As for the site‐specific cancers, significant excesses were reported for stomach, central nervous system, respiratory, and pancreas cancer with a variability according to psychiatric diagnosis and gender.

Conclusions

Patients suffering from SMI had higher mortality risk than the regional population with some differences according to cancer type, gender, and psychiatric diagnosis. Proper cancer preventive and treatment interventions, including more effective risk modification strategies (e.g., smoking cessation, dietary habits) and screening for cancer, should be part of the agenda of all mental health departments in conjunction with other health care organizations, including psycho‐oncology.

Influence of adherence with guideline-driven recommendations on survival in women operated for breast cancer: Real-life evidence from Italy

BACKGROUND

A set of indicators to assess the quality of care for women operated for breast cancer was developed by an expert working group of the Italian Health Ministry in order to compare the Italian regions. A study to validate these indicators through their relationship with survival was carried out.

METHODS

The 16,753 women who were residents in three Italian regions (Lombardy, Emilia-Romagna and Lazio) and hospitalized for breast cancer surgery during 2011 entered the cohort and were followed until 2016. Adherence to selected recommendations (i.e., surgery timeliness, medical therapy timeliness, appropriateness of complementary radiotherapy and mammographic follow-up) was assessed. Multivariable proportional hazards models were fitted to estimate hazard ratios for the association between adherence with recommendations and the risk of all-cause mortality.

RESULTS

Adherence to recommendations was 53% for medical therapy timeliness, 73% for appropriateness of mammographic follow-up, 74% for surgery timeliness and 82% for appropriateness of complementary radiotherapy. Risk reductions of 26%, 62% and 56% were observed for adherence to recommendations on medical therapy timeliness, appropriateness of complementary radiotherapy and mammographic follow-up, respectively. There was no evidence that mortality was affected by surgery timeliness.

CONCLUSIONS

Clinical benefits are expected from improvements in adherence to the considered recommendations. Close control of women operated for breast cancer through medical care timeliness and appropriateness of radiotherapy and mammographic monitoring must be considered the cornerstone of national guidance, national audits, and quality improvement incentive schemes.

Geographic Inequalities in Breast Cancer in Italy: Trend Analysis of Mortality and Risk Factors

We calculated time trends of standardised mortality rates and risk factors for breast cancer (BC) from 1990 to 2016 for all women resident in Italy. The age-standardised mortality rate in Italy decreased from 4.2 in 1990 to 3.2 (×100,000) in 2016. While participation in organised screening programmes and age-standardised fertility rates decreased in Italy, screening invitation coverage and mammography uptake, the prevalence of women who breastfed and mean age at birth increased. Although southern regions had favourable prevalence of protective risk factors in the 1990s, fertility rates decreased in southern regions and increased in northern regions, which in 2016 had a higher rate (1.28 vs. 1.32 child per woman) and a smaller increase in women who breastfed (+4% vs. +30%). In 2000, mammography screening uptake was lower in southern than in northern and central regions (28% vs. 52%). However, the increase in mammography uptake was higher in southern (203%) than in northern and central Italy (80%), reducing the gap. Participation in mammographic screening programmes decreased in southern Italy (−10%) but increased in the North (6.6%). Geographic differences in mortality and risk factor prevalence is diminishing, with the South losing all of its historical advantage in breast cancer mortality.

Early detection of breast cancer rectifies inequality of breast cancer outcomes

Objectives

To explain apparent differences among mammography screening services in Sweden using individual data on participation in screening and with breast cancer–specific survival as an outcome.

Methods

We analysed breast cancer survival data from the Swedish Cancer Register on breast cancer cases from nine Swedish counties diagnosed in women eligible for screening. Data were available on 38,278 breast cancers diagnosed and 4312 breast cancer deaths. Survival to death from breast cancer was estimated using the Kaplan–Meier estimate, for all cases in each county, and separately for cases of women participating and not participating in their last invitation to screening. Formal statistical comparisons of survival were made using proportional hazards regression.

Results

All counties showed a reduction in the hazard of breast cancer death with participation in screening, but the reductions for individual counties varied substantially, ranging from 51% (95% confidence interval 46–55%) to 81% (95% confidence interval 74–85%). Survival rates in nonparticipating women ranged from 53% (95% confidence interval 40–65%) to 74% (95% confidence interval 72–77%), while the corresponding survival in women participating in screening varied from 80% (95% confidence interval 77–84%) to 86% (95% confidence interval 83–88%), a considerably narrower range.

Conclusions

Differences among counties in the effect of screening on breast cancer outcomes were mainly due to variation in survival in women not participating in screening. Screening conferred similarly high survival rates in all counties. This indicates that the performance of screening services was similar across counties and that detection and treatment of breast cancer in early-stage reduces inequalities in breast cancer outcome.

Opportunistic screening for type 2 diabetes in community pharmacies. Results from a region-wide experience in Italy

Background and aims

Given the paucity of symptoms in the early stages of type 2 diabetes, its diagnosis is often made when complications have already arisen. Although systematic population-based screening is not recommended, there is room to experience new strategies for improving early diagnosis of the disease in high risk subjects. We report the results of an opportunistic screening for diabetes, implemented in the setting of community pharmacies.

Methods and results

To identify people at high risk to develop diabetes, pharmacists were trained to administer FINDRISC questionnaire to overweight, diabetes-free customers aged 45 or more. Each interviewee was followed for 365 days, searching in the administrative database whether he/she had a glycaemic or HbA1c test, or a diabetologists consultation, and to detect any new diagnosis of diabetes defined by either a prescription of any anti-hyperglycaemic drug, or the enrolment in the register of patients, or a hospital discharge with a diagnosis of diabetes.

Out of 5977 interviewees, 53% were at risk of developing diabetes. An elevated FINDRISC score was associated with higher age, lower education, and living alone. Excluding the number of cases expected, based on the incidence rate of diabetes in the population, 51 new cases were identified, one every 117 interviews. FINDRISC score, being a male and living alone were significantly associated with the diagnosis.

Conclusions

The implementation of a community pharmacy-based screening programme can contribute to reduce the burden of the disease, particularly focusing on people at higher risk, such as the elderly and the socially vulnerable.

Geographical and socioeconomic differences in uptake of Pap test and mammography in Italy: results from the National Health Interview Survey

OBJECTIVE

The Italian National Health Service instituted cervical and breast cancer screening programmes in 1999; the local health authorities have a mandate to implement these screening programmes by inviting all women aged 25-64 years for a Pap test every 3 years (or for an Human Papilloma Virus (HPV) test every 5 years) and women aged 50-69 years for a mammography every 2 years. However, the implementation of screening programmes throughout the country is still incomplete. This study aims to: (1) describe cervical and breast cancer screening uptake and (2) evaluate geographical and individual socioeconomic difference in screening uptake.

METHODS

Data both from the Italian National Health Interview Survey (NHIS) conducted by the National Institute of Statistics in 2012-2013 and from the Italian National Centre for Screening Monitoring (INCSM) were used. The NHIS interviewed a national representative random sample of 32 831 women aged 25-64 years and of 16 459 women aged 50-69 years. Logistic multilevel models were used to estimate the effect of socioeconomic variables and behavioural factors (level 1) on screening uptake. Data on screening invitation coverage at the regional level, taken from INCSM, were used as ecological (level 2) covariates.

RESULTS

Total 3-year Pap test and 2-year mammography uptake were 62.1% and 56.4%, respectively; screening programmes accounted for 1/3 and 1/2 of total test uptake, respectively. Strong geographical differences were observed. Uptake was associated with high educational levels, healthy behaviours, being a former smoker and being Italian versus foreign national. Differences in uptake between Italian regions were mostly explained by the invitation coverage to screening programmes.

CONCLUSIONS

The uptake of both screening programmes in Italy is still under acceptable levels. Screening programme implementation has the potential to reduce the health inequalities gap between regions but only if uptake increases.

Impact of breast cancer screening in a population with high spontaneous coverage with mammography

OBJECTIVE

The impact of organized screening programs on breast cancer (BC) mortality is unclear in an era of high spontaneous referral of women to mammography. The aim of this study was to analyze if the introduction of mammographic screening programs reduced BC mortality in the Veneto region, Italy, despite already widespread spontaneous access to mammography.

METHODS

In Veneto, screening was introduced in different years between 1999 and 2009 across 21 local health units (LHUs), inviting asymptomatic women aged 50-69 years to undergo mammography biennially. We compared BC mortality for the 1995-2014 period of women aged 40-49 and 50-74 years who were resident in LHUs where screening programs started in 2003 (early LHUs) with women resident in LHUs where screening was introduced later (late LHUs). Poisson regression models were applied to incidence-based mortality (IBM), including only deaths from BC arising within the screening period.

RESULTS

In the prescreening period and until 2010, BC mortality rates in early and late LHUs were similar in both age groups. In the last study period (2010-2014), we observed a 10% decrease in overall BC mortality in early compared to late LHU, limited to women aged 50-74 years. IBM was reduced by 8% (95% CI 1%-16%) in the overall study period and by 16% (6%-25%) in 2010-2014.

CONCLUSIONS

In the Veneto region, screening programs were associated with a significant impact on BC-specific mortality; such effect appeared at least 8 years after screening implementation.

Absence of socioeconomic inequalities in access to good-quality breast cancer treatment within a population-wide screening programme in Turin (Italy)

Several studies suggest that population-based breast cancer screening programmes might help reduce social inequalities in breast cancer survival both by increasing early diagnosis and by improving access to effective treatments. To start disentangling the two effects, we evaluated social inequalities in quality of treatment of screen-detected breast cancer in the city of Turin (Italy). Combining data from the Audit System on Quality of Breast Cancer Treatment and the Turin Longitudinal Study, we analysed 2700 cases in the screening target age class 50-69 diagnosed in the period 1995-2008. We selected 10 indicators of the pathway of care, relative to timeliness and appropriateness of diagnosis and treatment, and three indicators of socioeconomic position: education, occupational status and housing characteristics. For each indicator of care, relative risks of failure were estimated by robust Poisson regression models, controlling for calendar period of diagnosis, size of tumour and activity volume of the surgery units. The principal predictor of failure of the good care indicators was the calendar period of diagnosis, with a general improvement with time in the quality of diagnosis and treatment, followed by size of the tumour and volume of activity. Socioeconomic indicators show only a marginal independent effect on timeliness indicators. The observed associations of quality indicators with socioeconomic characteristics are lower than expected, suggesting a possible role of the screening programme in reducing disparities in the access to good-quality treatments thanks to its capability to enter screen-detected women into a protected pathway of care.

Socioeconomic deprivation worsens the outcomes of Italian women with hormone receptor-positive breast cancer and decreases the possibility of receiving standard care

BACKGROUND

Socioeconomic factors influence access to cancer care and survival. This study investigated the role of socioeconomic status on the risk of breast cancer recurrence and on the delivery of appropriate cancer care (sentinel lymph node biopsy and breast-conserving surgery plus radiotherapy), by patients' age and hormone receptor status.

METHODS

3,462 breast cancer cases diagnosed in 2003-2005 were selected from 7 Italian cancer registries and assigned to a socioeconomic tertile on the basis of the deprivation index of their census tract. Multivariable models were applied to assess the delivery of sentinel lymph node biopsy and of breast-conserving surgery plus radiotherapy within socioeconomic tertiles.

RESULTS

In the 1,893 women younger than 65 years, the 5-year risk of recurrence was higher in the most deprived group than in the least deprived, but this difference was not significant (16.4% vs. 12.9%, log-rank p=0.08); no difference was seen in women ≥65 years. Among the 2,024 women with hormone receptor-positive cancer, the 5-year risk was significantly higher in the most deprived group than in the least deprived one (13.0% vs. 8.9%, p=0.04); no difference was seen in cases of hormone receptor-negative cancer. The most deprived women were less likely than the least deprived women to receive sentinel lymph node biopsy (adjusted odds ratio (ORa), 0.69; 95% CI, 0.56-0.86) and to undergo breast-conserving surgery plus radiotherapy (ORa=0.66; 95% CI, 0.51-0.86). Conclusions: Socioeconomic inequalities affect the risk of recurrence, among patients with hormone receptor-positive cancer, and the opportunity to receive standard care.

Differences in mortality among women with breast cancer by income – a register-based study in Finland

Aims: The aim was to assess all-cause and breast cancer mortality by income among women with incident breast cancer and the effect of cancer stage at diagnosis and comorbidity on the differences. Methods: The 43,439 women (age ⩾30) diagnosed with breast cancer in 1998–2008 in Finland were monitored using individual-level Cancer Registry data supplemented with data from Finnish health care registers and sociodemographic data. Results: Overall mortality was greater among breast cancer patients of the lowest income group than in the highest one; the hazard ratio (HR) for age and incidence year adjusted all-cause mortality was 1.9 (95% CI 1.8–2.1) and for breast cancer mortality 2.0 (95% CI 1.8–2.2). The women from the lowest income group were over-represented in the breast cancer stage ‘distant’ (10.1% vs. 3.5% among the highest income group). The presence of comorbidities was more common in patients with the lowest income (at least one comorbidity in 54%) than in the highest (24%). The HR adjusted with stage at presentation and comorbidities was 1.6 (95% CI 1.4–1.7) for all-cause mortality and 1.6 (95% CI 1.4–1.7) for breast cancer mortality. Conclusions: Tumour stage at diagnosis was more severe among lower income groups, and the presence of comorbidities was more common, although this only accounted for a part of the higher breast cancer mortality in these groups. More information is needed about recognition, diagnosis and treatment of breast cancer to examine whether the socioeconomic differences of breast cancer mortality are related to care.

Economic evaluation of the breast cancer screening programme in the Basque Country: retrospective cost-effectiveness and budget impact analysis

Background

Breast cancer screening in the Basque Country has shown 20 % reduction of the number of BC deaths and an acceptable overdiagnosis level (4 % of screen detected BC). The aim of this study was to evaluate the breast cancer early detection programme in the Basque Country in terms of retrospective cost-effectiveness and budget impact from 1996 to 2011.

Methods

A discrete event simulation model was built to reproduce the natural history of breast cancer (BC). We estimated for lifetime follow-up the total cost of BC (screening, diagnosis and treatment), as well as quality-adjusted life years (QALY), for women invited to participate in the evaluated programme during the 15-year period in the actual screening scenario and in a hypothetical unscreened scenario. An incremental cost-effectiveness ratio was calculated with the use of aggregated costs. Besides, annual costs were considered for budget impact analysis. Both population level and single-cohort analysis were performed. A probabilistic sensitivity analysis was applied to assess the impact of parameters uncertainty.

Results

The actual screening programme involved a cost of 1,127 million euros and provided 6.7 million QALYs over the lifetime of the target population, resulting in a gain of 8,666 QALYs for an additional cost of 36.4 million euros, compared with the unscreened scenario. Thus, the incremental cost-effectiveness ratio was 4,214€/QALY. All the model runs in the probabilistic sensitivity analysis resulted in an incremental cost-effectiveness ratio lower than 10,000€/QALY. The screening programme involved an increase of the annual budget of the Basque Health Service by 5.2 million euros from year 2000 onwards.

Conclusions

The BC screening programme in the Basque Country proved to be cost-effective during the evaluated period and determined an affordable budget impact. These results confirm the epidemiological benefits related to the centralised screening system and support the continuation of the programme.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-016-2386-y) contains supplementary material, which is available to authorized users.

Impact of deprivation on breast cancer survival among women eligible for mammographic screening in the West Midlands (UK) and New South Wales (Australia): Women diagnosed 1997-2006

Women diagnosed with breast cancer in the UK display marked differences in survival between categories defined by socio-economic deprivation. Timeliness of diagnosis is one of the possible explanations for these patterns. Women whose cancer is screen-detected are more likely to be diagnosed at an earlier stage. We examined deprivation and screening-specific survival in order to evaluate the role of early diagnosis upon deprivation-specific survival differences in the West Midlands (UK) and New South Wales (Australia). We estimated net survival for women aged 50-65 years at diagnosis and whom had been continuously eligible for screening from the age of 50. Records for 5,628 women in West Midlands (98.5% of those eligible, mean age at diagnosis 53.7 years) and 6,396 women in New South Wales (99.9% of those eligible, mean age at diagnosis 53.8 years). In New South Wales, survival was similar amongst affluent and deprived women, regardless of whether their cancer was screen-detected or not. In the West Midlands, there were large and persistent differences in survival between affluent and deprived women. Deprivation differences were similar between the screen-detected and non-screen detected groups. These differences are unlikely to be solely explained by artefact, or by patient or tumour factors. Further investigations into the timeliness and appropriateness of the treatments received by women with breast cancer across the social spectrum in the UK are warranted.

Optimising colorectal cancer screening acceptance: a review

The study aims to review available evidence concerning effective interventions to increase colorectal cancer (CRC) screening acceptance. We performed a literature search of randomised trials designed to increase individuals' use of CRC screening on PubMed, Embase, Cochrane Database of Systematic Reviews and Database of Abstracts of Reviews of Effects. Small (≤ 100 subjects per arm) studies and those reporting results of interventions implemented before publication of the large faecal occult blood test trials were excluded. Interventions were categorised following the Continuum of Cancer Care and the PRECEDE-PROCEED models and studies were grouped by screening model (opportunistic vs organised). Multifactor interventions targeting multiple levels of care and considering factors outside the individual clinician control, represent the most effective strategy to enhance CRC screening acceptance. Removing financial barriers, implementing methods allowing a systematic contact of the whole target population, using personal invitation letters, preferably signed by the reference care provider, and reminders mailed to all non-attendees are highly effective in enhancing CRC screening acceptance. Physician reminders may support the diffusion of screening, but they can be effective only for individuals who have access to and make use of healthcare services. Educational interventions for patients and providers are effective, but the implementation of organisational measures may be necessary to favour their impact. Available evidence indicates that organised programmes allow to achieve an extensive coverage and to enhance equity of access, while maximising the health impact of screening. They provide at the same time an infrastructure allowing to achieve a more favourable cost-effectiveness profile of potentially effective strategies, which would not be sustainable in opportunistic settings.