Screening In Europe Research Articles

Our journey toward implementation of digital breast tomosynthesis in breast cancer screening: the Malmö Breast Tomosynthesis Screening Project.

The purpose is to describe the Malmö Breast Tomosynthesis Screening Project from the beginning to where we are now, and thoughts for the future. In two acts, we describe the efforts made by our research group to improve breast cancer screening by introducing digital breast tomosynthesis (DBT), all the way from initial studies to a large prospective population-based screening trial and beyond. Our studies have shown that DBT has significant advantages over digital mammography (DM), the current gold standard method for breast cancer screening in Europe, in many aspects except a major one-the increased radiologist workload introduced with DBT compared with DM. It is foreseen that AI could be a viable solution to overcome this problem. We have proved that one-view DBT is a highly efficient screening approach with respect to diagnostic performance.

Systematic review of cost-effectiveness studies on cervical cancer screening across Europe

IntroductionCervical cancer (CC) is a type of cancer with poor prognosis when diagnosed in advanced stage with a big socioeconomic burden. The incidence rates have wide variations among European countries depending on the implementation or not of screening, vaccination programs and the human development index (HDI). Most studies on cost-effectiveness of CC screening programs are carried out in countries with a high HDI, however more recent reviews of screening approaches are coming from countries with lower HDI aiming to identify the best screening strategies. Our study aims to identify which are the currently applied and most cost-effective strategies of CC screening in Europe. Materials and methodsThis is a systematic review conducted in three different databases (PubMed, Scopus and ScienceDirect) and reported following the PRISMA guidelines. General key terms for all databases were the following: cost-effectiveness, cervical cancer, screening, Europe. We included studies in English, Italian, Spanish and Bulgarian, published in the last 25 years, reporting data on cost-effectiveness of CC screening, costs and outcome measures. The methodological quality of the articles was evaluated with a standardized tool. ResultsA total of 262 studies were identified and 22 studies were included in the final analysis. In 90.1 % of the economic studies, the new screening strategy was shown to be more cost-effective compared to the current one or compared to no screening. The optimal strategy mostly involved primary HPV testing, combined with cytology or as stand-alone screening technique. Several scenarios differing on starting age and periodicities for CC screening, combination of techniques and triage, were found to be cost-effective and below the willingness to pay (WTP) threshold. The methodology of all included studies was assessed from 10 to 11 on the JBI standardized tool and Drummond 11-point checklist. ConclusionNumerous cost-effective options for CC screening in different European countries were identified in this systematic review. HPV testing, with or without cytology, mainly starting at 30 years of age and repeated every 5 years or more was the most cost-effective technique. Future studies should focus on the most appropriate CC screening approach for each context and setting, also considering HPV vaccination in Europe.

Development and pilot implementation of a novel protocol to assess capacity and readiness of health systems to adopt HPV detection-based cervical cancer screening in Europe

BackgroundCervical cancer remains a significant public health concern in Europe. Effective introduction and scaling up of human papillomavirus (HPV) detection-based cervical cancer screening (CCS) requires a systematic assessment of health systems capacity. However, there is no validated capacity assessment methodology for CCS programmes, especially in European contexts. Addressing this gap, our study introduces an innovative and adaptable protocol for evaluating the capacity of CCS programmes across varying European health system settings.MethodsOur research team developed a three-step capacity assessment framework, incorporating a health policy review checklist, a facility visit survey, and key informants’ interview guide followed by a strengths, weaknesses, opportunities and threats (SWOT) analysis. Piloting this comprehensive approach, we explored the CCS capacity in three countries: Estonia, Portugal and Romania. These countries were selected due to their contrasting healthcare structures and resources, providing a diverse overview of the European context.ResultsConducted over a period of 9 months, the capacity assessment covered multiple resources, 27 screening centres, 16 colposcopy and treatment centres and 15 key informant interviews. Our analysis highlighted both shared and country-specific challenges. A key common issue was ensuring high compliance to follow-up and management of screen-positive women. We identified considerable heterogeneity in resources and organization across the three countries, underscoring the need for tailored, rather than one-size-fits-all, solutions.ConclusionsOur study’s novelty lies in the successful development of this capacity assessment methodology implementable within a relatively short time frame, proving its feasibility for use in various contexts and countries. The resulting set of materials, adaptable to different cancer types, is a ready-to-use toolkit to improve cancer screening processes and outcomes. This research marks a significant stride towards comprehensive capacity assessment for CCS programmes in Europe. Future directions include deploying these tools in other countries and cancer types, thereby contributing to the global fight against cancer.

Projected effectiveness of lung cancer screening and concurrent smoking cessation support in the Netherlands

The NELSON trial demonstrated a 24% intention-to-screen reduction in lung cancer mortality from regular screening with low-dose computed tomography. Implementation efforts in Europe are ongoing, but still await country-specific and NELSON-adapted estimates of the benefits and harms of screening. We use the MISCAN-Lung microsimulation model, calibrated to individual-level outcomes from the NELSON trial, to estimate the effectiveness under 100% compliance of biennial lung cancer screening with concomitant smoking cessation support for Dutch cohorts 1942-1961. The model simulates smoking behaviour, lung cancer incidence and the effects of screening and smoking cessation on lung- and other-cause mortality. We find biennial screening with eligibility criteria equal to those of the 4-IN-THE-LUNG-RUN implementation trial to reduce lung cancer mortality by 16.9% among the eligible population, equivalent to 1076 LC deaths prevented per year in the next two decades. Eligible individuals constitute 21.5% of the cohorts studied, and stand to face 61% of the projected lung cancer mortality burden in the absence of screening. 10.3 life-years are gained per prevented LC death, for 14.9 screens per life year gained. Concomitant smoking cessation interventions may increase the expected gains in life years from screening by up to 20%. Policy makers should imminently consider the implementation of lung cancer screening in Europe, paired with effective smoking cessation interventions. Smoking cessation interventions on their own are not estimated to yield a gain in remaining life expectancy of the magnitude offered by even a single CT screen. European UnionHorizon 2020 grant 848294: 4-IN-THE-LUNG-RUN.

Mydriasis for retinopathy of prematurity screening in Europe: A cross-sectional online survey.

To compile real-time data on the preferred mydriasis practice patterns for retinopathy of prematurity (ROP) screening in Europe. A cross-sectional online survey was conducted from December 2022 to January 2023, using a self-report online questionnaire which was distributed via email to the members of the European Pediatric Ophthalmological Society and the Greek National ROP Task Force. A six-week period of recruitment was determined, and a reminder email was sent after two weeks. Descriptive statistics were used to explore the data, which was summarized with frequencies and percentages. Sixty-six responses were recorded (response rate: 29.5%), representing practices in 55 Neonatal Intensive Care Units from 21 European countries. In 94.5%, the applied mydriatic regimen consists of phenylephrine with at least one muscarinic antagonist, either tropicamide or cyclopentolate. The concentration of phenylephrine ranges from 0.5% to 5%, of tropicamide from 0.25% to 1%, and of cyclopentolate from 0.2% to 1%. The most commonly used regimen (43.6%) contains phenylephrine 2.5% and tropicamide 0.5%, administered either combined or separately. About 54.5% of the reported mydriatic solutions are non-commercial, in-house preparations. Systemic adverse events, including oxygen desaturation, bradycardia and cardiopulmonary arrest were reported in 14.5%. There is considerable heterogeneity in the applied mydriatic regimens for ROP screening in Europe, reflecting the absence of universal guidelines. The wide use of in-house preparations underlines the gap in the pharmaceutical industry. Concern should be raised against the wide use of undiluted commercial drugs, that reach adult dose, in the fragile population of preterm infants.

Factors influencing the participation of groups identified as underserved in cervical cancer screening in Europe: a scoping review of the literature.

Cervical cancer is a preventable and inequitably distributed disease. Screening plays a vital role in prevention, but many women face barriers to participation. The aims of this scoping review, undertaken to inform the co-design of interventions to equitably increase screening uptake, were to: (1) identify barriers and facilitators to cervical cancer screening for underserved populations, and (2) identify and describe the effectiveness of interventions aimed at improving participation in cervical cancer screening among underserved groups in Europe. Qualitative, quantitative, and mixed methods studies focusing on barriers and facilitators to cervical screening participation and interventions to improve uptake undertaken in Europe and published after 2000 were included. Four electronic databases were searched to identify relevant papers. Titles and abstracts were screened, full text reviewed, and key findings extracted. Data were extracted and analyzed according to different health system strata: system-wide (macro), service specific (meso) and individual/community specific (micro). Within these categories, themes were identified, and the population groups impacted were recorded. All findings are presented in accordance with (PRISMA) guidelines. 33 studies on barriers and facilitators and eight intervention studies met the inclusion criteria. Collectively, the findings of these studies presented a wide array of screening uptake barriers, facilitators, and interventions, predominantly related to screening service and individual/community factors. However, although diverse, certain core themes around information provision, prompts for participation and the need for inclusive spaces were apparent. Implementation of screening programs should focus on: (1) reducing identifiable barriers, (2) increasing public awareness, and (3) providing patient reminders and measures to promote engagement by healthcare providers. There are many barriers to uptake of cervical cancer screening and this review, nested within a larger study, will inform work to devise a solution alongside groups identified in three European countries.

Naïve no more: Foreign direct investment screening in the European Union

AbstractThis paper asks what explains the creation and comparative features of national Investment Screening Mechanisms (ISMs) in Europe. After providing a brief history and definition of ISMs, we provide descriptive patterns about the similarities and differences in the investment screening features of national ISMs in EU member states. We then explain differences in national screening policies by focusing on the role of public debt, Chinese investment, R&D expenditures and various geographic groupings. Finally, we make three policy arguments about the rise of ISMs in Europe: (1) ISMs have not been designed as protectionist instruments, (2) the politics of inward investment screening reflects a shift from economic to security logic in addressing the fundamental tension between the benefits and vulnerabilities of open markets and (3) the EU can use the ‘commercialisation’ of security to extend its own competence in the security sphere. We conclude by considering how the rapid expansion of investment screening in Europe could affect economic openness, as well as the role of the EU as a global actor.

Recommendations for Prostate Cancer Screening in Europe

FOR the first time, prostate-specific antigen (PSA)-based prostate cancer screening has been included in the Screening Recommendations published by the European Commission (EC). A series of presentations and discussions were held at the European Association of Urology (EAU) 2023 Congress in Milan, Italy, on how European Union (EU) member states should swiftly implement these recommendations in their own populations. Emphasis was placed on raising awareness and promoting risk stratification before biopsy to reduce overdiagnosis.

Paediatric familial hypercholesterolaemia screening in Europe: public policy background and recommendations.

Familial hypercholesterolaemia (FH) is under-recognized and under-treated in Europe leading to significantly higher risk for premature heart disease in those affected. As treatment beginning early in life is highly effective in preventing heart disease and cost-effective in these patients, screening for FH is crucial. It has therefore now been recognized by the European Commission Public Health Best Practice Portal as an effective strategy. Model programmes exist in Europe to identify young individuals with FH, which are based on cascade screening of first-degree relatives of affected individuals, universal screening for high cholesterol, opportunistic screening of high-risk individuals, or a combination of the above approaches. Recommendations presented herein to improve identification of FH emphasize that every country should have an FH screening programme. These programmes should be adapted from existing strategies to best fit the individual country's healthcare system, governments should provide financial support for these programmes and related care, and further research to optimize care and implementations should be conducted.

Cervical cancer (over-)screening in Europe: Balancing organised and opportunistic programmes.

Cervical cancer (CC) over-screening has been understudied in Europe, yet is relevant for approaching inequalities in screening uptake. Focusing on countries' screening strategies (opportunistic systems versus organised programmes), we assess in which contexts CC over-screening is more prevalent, and which women are more likely to have engaged in cervical cancer screening (CCS) within the past year. A two-level (multilevel) design among screening women (N = 80,761) nested in 31 European countries was used to analyse data from the second wave (2013-2015) of the European Health Interview Survey. We focused on over-screening, defined as screening more frequently than the three-yearly screening interval prescribed in the European guidelines - that is, having screened within the past year. Higher levels of over-screening were observed in opportunistic systems compared to systems with organised programmes. In opportunistic systems, women with a higher socioeconomic position had a higher likelihood of being screened within the past year than their socioeconomic counterparts. Moreover, these differences diminished under organised programmes. Contexts with organised CCS programmes are more efficiently reducing over-screening, and enforcing the European guidelines. We suggest that the physician-patient relationship is an essential pathway for explaining socioeconomic differences in CC (over-)screening and for future interventions.

Lung Cancer Screening: New Perspective and Challenges in Europe.

Simple SummaryScreening for lung cancer in a high-risk population has been shown to be beneficial, with reduced mortality in large randomised trials. However, the general implementation of screening is not evident and many factors have to be considered. In this paper, we will review the current status of screening for lung cancer in Europe and the many hurdles that have to be overcome. Multidisciplinary cooperation between all specialists dealing with lung cancer is required to obtain the best outcome. Hopefully, Europe’s Beating Cancer Plan will incorporate screening for lung cancer to allow general implementation by similar programmes in every European Member State. This will also provide an opportunity for further, large-scale studies to refine the inclusion of specific risk populations, diagnosis and management of screen-detected nodules.Randomized-controlled trials have shown clear evidence that lung cancer screening with low-dose CT in a high-risk population of current or former smokers can significantly reduce lung-cancer-specific mortality by an inversion of stage distribution at diagnosis. This paper will review areas in which there is good or emerging evidence and areas which still require investment, research or represent implementation challenges. The implementation of population-based lung cancer screening in Europe is variable and fragmented. A number of European countries seem be on the verge of implementing lung cancer screening, mainly through the implementation of studies or trials. The cost and capacity of CT scanners and radiologists are considered to be the main hurdles for future implementation. Actions by the European Commission, related to its published Europe’s Beating Cancer Plan and the proposal to update recommendations on cancer screening, could be an incentive to help speed up its implementation.

One-off low-dose CT lung cancer screening in China: an appropriate strategy?

Lung cancer is devastating, with a 5-year survival rate of about 10%. High smoking prevalence in the past means that millions of people are at high risk of developing lung cancer. Two large-scale randomised controlled trials (RCTs) have shown that screening with high-quality, low-dose CT (LDCT) can detect lung cancer substantially earlier than when being diagnosed symptomatically, and thereby reduce mortality from the disease by 8–24% (point estimates of trials) in men and by 26–61% in women. 1 de Koning HJ van der Aalst CM de Jong PA et al. Reduced lung-cancer mortality with volume CT screening in a randomized trial. N Engl J Med. 2020; 382: 503-513 Crossref PubMed Scopus (957) Google Scholar , 2 Aberle DR Adams AM Berg CD et al. Reduced lung-cancer mortality with low-dose computed tomographic screening. N Engl J Med. 2011; 365: 395-409 Crossref PubMed Scopus (6627) Google Scholar The LUSI RCT recently confirmed that repeated LDCT is associated with a reduction in lung cancer mortality in women. 3 Becker N Motsch E Trotter A et al. Lung cancer mortality reduction by LDCT screening—results from the randomized German LUSI trial. Int J Cancer. 2020; 146: 1503-1513 Crossref PubMed Scopus (173) Google Scholar The evidence from these trials has led the way to careful but slow progress in implementation studies throughout Europe, 4 Rzyman W Szurowska E Adamek M Implementation of lung cancer screening at the national level: Polish example. Transl Lung Cancer Res. 2019; 8: S95-105 Crossref PubMed Scopus (20) Google Scholar , 5 Balata H Ruparel M O'Dowd E et al. Analysis of the baseline performance of five UK lung cancer screening programmes. Lung Cancer. 2021; 161: 136-140 Summary Full Text Full Text PDF PubMed Scopus (7) Google Scholar , 6 Van der Aalst C Oudkerk M Haaf KT et al. Towards personalized lung cancer CT screening in Europe. Eur Respir J. 2020; 564171 Google Scholar insurance coverage in the USA (by the B recommendations of the US Preventive Services Task Force), 7 Meza R Jeon J Toumazis I et al. Evaluation of the benefits and harms of lung cancer screening with low-dose computed tomography: modeling study for the US Preventive Services Task Force. JAMA. 2021; 325: 988-997 Crossref PubMed Scopus (70) Google Scholar and preliminary recommendations in Australia and Europe to consider national lung cancer screening programmes. The common aim of such programmes is to invite current and former smokers in the age range 50–80 years with a specific expected minimum risk (eg, current or former smoking history of 20 pack-years, or a minimum PLCOm2012 risk score of around 2–3% for developing lung cancer in the next 6 years, with no difference between the sexes) for LDCT screening. But can the results of trials that were done in high-income countries with largely White populations simply be applied to other ethnic groups, such as those of Chinese and Asian descent, in which other risk profiles seem to be important too? In China, especially in women, the proportion of lung cancer cases attributable to tobacco use is only about 18%. 8 Li N Tan F Chen W et al. One-off low-dose CT for lung cancer screening in China: a multicentre, population-based, prospective cohort study. Lancet Respir Med. 2022; (published online March 8.)https://doi.org/10.1016/S2213-2600(21)00560-9 Summary Full Text Full Text PDF Scopus (9) Google Scholar Notably, more than 700 000 lung cancer deaths were estimated in China in 2020, which is 40% of the total lung cancer deaths worldwide. 9 Ferlay JEM Lam F Colombet M et al. Global Cancer Observatory: cancer today. International Agency for Research on Cancer, Lyon, France2022https://gco.iarc.fr/today/online-analysis-table?v=2020&mode=cancer&mode_population=countries&population=900&populations=935_908_900_160&key=asr&sex=0&cancer=39&type=1&statistic=5&prevalence=0&population_group=0&ages_group%5B%5D=0&ages_group%5B%5D=17&group_cancer=1&include_nmsc=0&include_nmsc_other=1#collapse-group-0-3Date accessed: January 18, 2022 Google Scholar One-off low-dose CT for lung cancer screening in China: a multicentre, population-based, prospective cohort studyOne-off LDCT screening was associated with significantly lower lung cancer mortality and all-cause mortality in a large population in China. Our results point to the promise of one-off LDCT screening in countries with limited medical resources. Further studies are needed to explore interactions by subgroup—including sex, age, smoking status, and economic status—to develop population-specific screening strategies. Full-Text PDF

Newborn screening as a fully integrated system to stimulate equity in neonatal screening in Europe.

Newborn screening as a fully integrated system to stimulate equity in neonatal screening in Europe.

Population effects associated with colorectal cancer screening in Europe

Population effects associated with colorectal cancer screening in Europe

Lung cancer screening: a critical appraisal.

The recently published large-scale NELSON trial showed a reduction in lung cancer (LC) mortality with the use of low-dose computed tomography (LDCT) in high-risk patients. This is the first such European-based trial to mirror the results of the US National Lung Screening Trial (NLST). The NLST was responsible for nationwide implementation of LC screening protocols which has shown a decrease in LC mortality. However, the implementation of such screening in Europe has been challenging. With the findings from the NELSON trial, implementation of LC screening throughout Europe should once again be evaluated. This review article further elaborates on the advantages of LDCT in LC screening. It also discusses promising future approaches that can supplement the current LC screening guidelines. Implementation of LC screening with LDCT should again be evaluated throughout Europe as it could substantially decrease LC-related mortality.

Colorectal cancer screening in Europe: what are the next steps?

In The Lancet Oncology, Rafael Cardoso and colleagues 1 Cardoso R Guo F Heisser T et al. Divergent trends in colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population-based study. Lancet Oncol. 2021; (published online May 25.)https://doi.org/10.1016/S1470-2045(21)00199-6 Summary Full Text Full Text PDF Scopus (9) Google Scholar present data from an international population-based study aiming to describe the effects of colorectal cancer screening on incidence, stage distribution, and mortality across European countries over the past two decades. The authors examine their findings according to the time of implementation of national screening programmes in this time period (early vs late), or as compared with countries with no large-scale screening programmes. The authors should be commended for establishing a large European research collaboration, thereby providing a unique opportunity to uncover important findings on various aspects of colorectal cancer screening. Colorectal cancer incidence, mortality, and stage distribution in European countries in the colorectal cancer screening era: an international population-based studyWe observed divergent trends in colorectal cancer incidence, mortality, and stage distribution across European countries, which appear to be largely explained by different levels of colorectal cancer screening implementation. Full-Text PDF

Neonatal screening in Europe revisited: An ISNS-perspective on the current state and developments since 2010

Neonatal screening (NBS) was initiated in Europe during the 1960s with the screening for phenylketonuria. The panel of screened disorders ("conditions") then gradually expanded, with a boost in the late 1990's with the introduction of tandem mass spectrometry (MS/MS), making it possible to screen for 40-50 conditions in one blood spot. The most recent additions to screening programmes (screening for cystic fibrosis, severe combined immunodeficiency and spinal muscular atrophy) were assisted by or realised through the introduction of molecular genetics techniques. For this survey we collected data from 51 European countries. We report on the developments between 2010 and 2020, and highlight the achievements made during this period. We also identify areas where further progress can be made, mainly by exchanging knowledge and learning from experiences in neighbouring countries. Between 2010 and 2020, most NBS programmes in geographical Europe have matured considerably, both in terms of methodology (modernised) and with regards to the panel of conditions screened (expanded). These developments indicate that more collaboration in Europe through European organisations is gaining momentum. Only by working together can we accomplish the timely detection of newborn infants potentially suffering from one of the many rare diseases and take appropriate actions.

Lung cancer screening in Europe: where are we in 2021?

This manuscript reviews the recent evidence obtained in lung cancer screening with low dose spiral CT-scan (LDSCT) and focuses on the issues associated with its implementation in Europe. After a review of the magnitude of the lung cancer toll in lives, disease and Euro’s, the recently released data of the major lung cancer screening trials are reviewed and mirrored with the results of the US National Lung Screening Trial (NLST), comparing their strengths and weaknesses and areas of future research. The specific barriers and hurdles to be addressed for widely implementing this population screening in European countries are discussed, with special emphasis on the issues of inclusion of smokers, smoking cessation interventions, radiation injury and capacity planning. The pros and cons of including current smokers will be addressed together with the issue which is the better smoking cessation intervention. A medical physicist’s view on radiation exposure and quality control will address concerns about radiation induced cancers. The downstream effects of a LDSCT screening program on the capacity of CT-scans, radiologists, thoracic surgeons and radiation oncologists will follow. An estimated roadmap for the future is sketched with the expected role of all key stakeholders. This roadmap reflects the opinion leader’s reflections as expressed in a number of discussions with European health authorities, taking place as part of the recently released European Beating Cancer plan.

Neonatal Screening in Europe Revisited: An ISNS Perspective on the Current State and Developments Since 2010.

Neonatal screening (NBS) was initiated in Europe during the 1960s with the screening for phenylketonuria. The panel of screened disorders (“conditions”) then gradually expanded, with a boost in the late 1990s with the introduction of tandem mass spectrometry (MS/MS), making it possible to screen for 40–50 conditions using a single blood spot. The most recent additions to screening programmes (screening for cystic fibrosis, severe combined immunodeficiency and spinal muscular atrophy) were assisted by or realised through the introduction of molecular technologies. For this survey, we collected data from 51 European countries. We report the developments between 2010 and 2020 and highlight the achievements reached with the progress made in this period. We also identify areas where further progress can be made, mainly by exchanging knowledge and learning from experiences in neighbouring countries. Between 2010 and 2020, most NBS programmes in geographical Europe matured considerably, both in terms of methodology (modernised) and with regard to the panel of conditions screened (expanded). These developments indicate that more collaboration in Europe through European organisations is gaining momentum. We can only accomplish the timely detection of newborn infants potentially suffering from one of the many rare diseases and take appropriate action by working together.

Development and Validation of Three Regional Microsimulation Models for Predicting Colorectal Cancer Screening Benefits in Europe.

Background. Validated microsimulation models have been shown to be useful tools in providing support for colorectal cancer (CRC) screening decisions. Aiming to assist European countries in reducing CRC mortality, we developed and validated three regional models for evaluating CRC screening in Europe. Methods. Microsimulation Screening Analysis–Colon (MISCAN-Colon) model versions for Italy, Slovenia, and Finland were quantified using data from different national institutions. These models were validated against the best available evidence for the effectiveness of screening from their region (when available): the Screening for COlon REctum (SCORE) trial and the Florentine fecal immunochemical test (FIT) screening study for Italy; the Norwegian Colorectal Cancer Prevention (NORCCAP) trial and the guaiac fecal occult blood test (gFOBT) Finnish population-based study for Finland. When published evidence was not available (Slovenia), the model was validated using cancer registry data. Results. Our three models reproduced age-specific CRC incidence rates and stage distributions in the prescreening period. Moreover, the Italian and Finnish models replicated CRC mortality reductions (reasonably) well against the best available evidence. CRC mortality reductions were predicted slightly larger than those observed (except for the Florentine FIT study), but consistently within the corresponding 95% confidence intervals. Conclusions. Our findings corroborate the MISCAN-Colon reliability in supporting decision making on CRC screening. Furthermore, our study provides the model structure for an additional tool (EU-TOPIA CRC evaluation tool: http://miscan.eu-topia.org) that aims to help policymakers and researchers monitoring or improving CRC screening in Europe.