Academic literature on the topic 'Rapid Diagnostic Tests (RDTs)'

It is an endemic vector-borne parasitic disease caused by protozoan parasites of the genus Plasmodium in tropical and subtropical regions worldwide. In each endemic area, malaria is transmitted by a specific set of Anopheles species. Plasmodium consists of over 200 species, infecting mammals, birds, and reptiles, and malaria parasites generally tend to be host-specific. Plasmodium falciparum, Plasmodium vivax, Plasmodium malariae, Plasmodium ovale, and Plasmodium knowlesi are the five known species of the genus Plasmodium that causes malaria in humans. Of the five Plasmodium species that cause malaria in humans, P. falciparum causes severe malaria. P. vivax is the most widespread malaria parasite globally. P. malariae is the least frequent and pathogenic, causing mainly asymptomatic infections with submicroscopic parasitemia, leading to low morbidity and mortality, although it can occasionally evolve with chronic renal disease. Different malaria species require distinct treatment regimens. Early and accurate diagnosis to specifically identify the infecting agent among all five malarial species is thus crucial for correct treatment and disease control. Prompt treatment is key to averting severe malaria and relies on access to accurate diagnosis and effective therapeutics. Several methods, such as microscopy-based analysis, rapid diagnostic test (RDT), serological methods, and molecular methods are available to diagnose malaria. Nucleic acid amplification tests (NAATs), which have advantages, such as high sensitivity and processivity and the capacity to identify drug-resistant strains, despite being more time consuming and expensive than microscopy and RDTs. PCR-based tests are also ideal for diagnosing mixed Plasmodium infections. However, PCR reliance on electricity, costly reagents and laboratory facilities for sample preparation have limited PCR to reference laboratories. To eliminate malaria, control and prevention efforts are necessary to reduce the prevalence of the disease and limit the development of drug resistance of the parasite. This requires a robust monitoring and surveillance system. Vector surveillance, larvae and vector control are also important. Vaccines and more recently, the use of monoclonal antibodies is needed for control of the disease. Enhanced surveillance and investigation of Plasmodium spp. genetic variations will contribute to the successful diagnosis and treatment of malaria in future.

"Diagnosing infections with SARS-CoV-2 is still of great interest due to the health and economic impact of COVID pandemic. The 4th wave of the COVID-19 pandemic is expected and is considered to be stronger and faster due to the dominance of Delta variant which is highly contagious [1]. SARS-CoV-2 also known as 2019-nCoV is one of the three coronaviruses (together with SARS-CoV or SARS-CoV1/Severe acute respiratory syndrome coronavirus), MERS-CoV /Middle East Respiratory Syndrome coronavirus) which can cause severe respiratory tract infections in humans [2]. Early diagnosis in COVID 19 infection is the key for preventing infection transmission in collectivity and proper medical care for the ill patients. Gold standard for diagnosing SARS-Co-V-2 infection according to WHO recommendation is using nucleic acid amplification tests (NAAT)/ reverse transcription polymerase chain reaction (RT-PCR). The search is on to develop reliable but less expensive and faster diagnostic tests that detect antigens specific for SARS-CoV-2 infection. Antigen-detection diagnostic tests are designed to directly detect SARSCoV-2 proteins produced by replicating virus in respiratory secretions so-called rapid diagnostic tests, or RDTs. The diagnostic development landscape is dynamic, with nearly a hundred companies developing or manufacturing rapid tests for SARS-CoV-2 antigen detection [3]. In the last 3 months our hospital introduced the antigen test or Rapid diagnostic tests (RDT) which detects the presence of viral proteins (antigens) expressed by the COVID-19 virus in a sample from the respiratory tract of a person. All RDT were confirmed next day with a RT-PCR. The number of positive cases detected during 3 months in our laboratory was 425. There were 326 positive tests in April, 106 positive tests in May and 7 positive tests in June. Compared with the number of positive tests in the 1st semester of 2021, the positive tests have significantly declined."

Malaria is a life-threatening mosquito-borne infectious disease, mainly caused by the plasmodium parasites. African continent still suffers the most from this disease for many reasons such as poverty, lack of awareness, lack of investments, insufficient infrastructure and precaution measures, weak policy as well as management, and improper diagnosis practices. In this research, we have performed extensive malaria data analysis for several African countries for the period 2000- 2020, and were able to extract some key insights for actionable insights. Our analysis shows that, overall, the continent has reduced the malaria infection rate from 37% to 25% (and associated death rates from 0.15% to 0.05%) in the last twenty years - a big achievement indeed. Unfortunately, some countries couldn’t follow this trend, leading the progress and the development curve to be stalled or constant and sometimes even negative for the last few years. These rates are still higher when we compare them to other parts of the world. We were also able to make some concrete associations with finances, associated investments, and the malaria diagnostics methodologies, adopted and practiced by certain countries. The overall healthcare spending (as a share of the Gross Domestic Product (GDP)) in Africa is way below the global healthcare spending as reported (5.6% vs 8.5%) in 2000 and (5.18% vs 9.8%) in 2019 by the World Health Organization (WHO). More alarming is, due to healthcare cuts, in recent years many countries switched from the more orthodox and effective microscopy diagnostics tests to comparatively cheaper and less effective Rapid Diagnostic Tests (RDTs) leading to severe consequences. We have made some concrete recommendations to combat malaria and to reduce infection and associated mortality rates.

INTRODUCTION Sexually transmitted infections (STI’s) are a public health threat. Syndromic approaches based on clinical symptoms have been suggested as having poor diagnostic performance, particularly in the type of settings where MSF is operational. We assessed the burden of STI’s and the diagnostic performance of a syndromic approach within an MSF-supported HIV/STI project in Eswatini. METHODS We conducted a cross-sectional study, enrolling adults accessing routine HIV testing and antiretroviral care services in six clinics in Shiselweni, from July 2022 to January 2023. HIV testing counselors performed HIV testing and nurses assessed patients for STI’s. Laboratory investigations included antibody-based rapid diagnostic tests (RDT’s) for Treponema pallidum (TP), hepatitis B (HBV) and hepatitis C (HBC). The molecular platform Xpert was used to test urine samples for Chlamydia trachomatis (CT), Neisseria gonorrhoea (NG), Trichomonas vaginalis (TV), Mycoplasma genitalium (MG), vaginal/anal swabs for human papillomavirus (HPV), and plasma for HIV viraemia to test for acute HIV infection (HIV). We calculated the prevalence of STI’s, and assessed diagnostic performance of a syndromic approach to diagnose male urethritis (MUS) and vaginal discharge (VDS) syndromes, versus laboratory-based testing. ETHICS This study was approved by the Eswatini Health and Human Research Review Board and by the MSF Ethics Review Board. RESULTS Of 1,041 study participants, 682 were women (65.5%), and the median age was 30 (interquartile range, IQR, 24-38) years. Overall, 280 (26.9%) were known HIV-positive and of 755 with unknown HIV status, 30 (4.0%) were newly diagnosed with HIV, of whom seven (23.3%) had AHI. 308 (29.6%) patients had at least one of the following three pathogens identified: NG 121 (11.6%); CT 155 (14.9%); TV 109 (10.5%). MG was detected in 33/330 participants (10.0%). In addition, 105 (10.1%) had antibodies against TP, 49 (4.7%) against HBV, and three (0.3%) against HCV. HPV prevalence was higher in tested women (104/196; 53.1%) versus men (5/27; 18.5%; p=0.001). Prevalence of NG/CT/TP was highest in newly-diagnosed HIV cases (48.2%) versus known HIV-positive cases (26.8%, p=0.019). Based on the syndromic approach, 188/634 (29.7%) had a VDS, and 97/334 (29.0%) a MUS. Diagnostic performance of the syndromic approach was better in men (MUS: sensitivity: 66.7%, specificity 87.5%; positive predictive value, PPV, 70.1%, negative predictive value, NPV, 85.7%), versus women (VDS: sensitivity 35.9%, specificity 72.9%; PPV 35.1%, NPV 73.5%). CONCLUSION A high burden of STI’s in Eswatini and poor diagnostic ability of the syndromic approach in this setting, calls for new approaches for STI care in MSF-supported sexual and reproductive health programmes in resource-poor settings. CONFLICTS OF INTEREST None declared

Background: On December 31, 2019, the World Health Organization (WHO) warned of pneumonia of unknown etiology in Wuhan, China. Rapid and accurate diagnosis of COVID-19 is crucial for the control of epidemic. Methods: In order to introduce a diagnosis and increase COVID-19 testing capacity, on March 27, 2020, Department of Medical Microbiology, University Clinical Center of Serbia was reorganized in staff and equipment. We started with molecular and serological diagnostics, and months later with tests for detection of SARS-CoV-2 antigen (Ag-RDT). On May 22, 2020, mass molecular testing at the National Laboratory for molecular diagnostics "Fire Eye" was started. Several real-time PCR (RT-PCR) protocols were applied. BGI RT-PCR (BGI Group, Shenzhen, China) was used for mass testing. The External Quality Control (EQC) was conducted in July 2020 and September 2021 (ECDC), and in December 2020 (WHO). Results: During two pandemic years 2021 and 2022, in Section of Virology we performed: 5.921 RT-PCRs, 75.807 Ag-RDT for detection of viral antigens, 37.373 rapid tests for detection of IgM and IgG antibodies and 491.995 RT-PCR tests in "Fire Eye" Laboratory. The EQC results confirmed the top quality of our work. For determining Omicron subvariants BA.1 and BA.2, in February 2022 we introduced Vir SNIP SARS-CoV-2 Spike S371L S373P Kit (TIB Molbiol, Berlin, Germany). Conclusions: In response to the challenges of the COVID-19 pandemic from a Department that processed up to 1.400 RT-PCR analyzes per year, we became a Department that issue up to 3.400 samples per day with EQC-certified quality and reliability.

Review question / Objective: This meta-analysis investigated the value of rsDECT -based non-invasive assessment of the severity of esophagus varices and the risk of hemorrhage in patients with cirrhotic portal hypertension. Eligibility criteria: Studies meeting the following criteria were included: Studies evaluating the effect of rsDECT on EV in patients with hepatic cirrhosis, and published in Chinese or English; The diagnosis was based on acknowledged gold standard. Containing complete four-grid table data of diagnostic tests, which can be extracted directly or indirectly. Review, case-report, conference summary, animal study, and repeatedly published study were excluded.Based on the severity of EV shown in the endoscopy, patients in the study group were classified into the mild EV (EV1), medium EV (EV2), or severe EV (EV3) groups according to the General Rules for Recording Endoscopic Findings of Esophagogastric varices (The Japan Society for Portal Hypertension) : EV1, slightly linear expansions; EV2, moderately beaded expansions; EV3, significantly nodular or neoplastic expansions.

Mycoplasma iowae (Mi) is a pathogenic avian mycoplasma which causes mortality in turkey embryos and as such has clinical and economic significance for the turkey breeder industry. Control of Mi infection is severely hampered by lack of adequate diagnostic tests, together with resistance to most antibiotics and resilience to environment. A markedly high degree of intra-species antigenic variation also contributes to difficulties in detection and control of infection. In this project we have designed an innovative gene-based diagnostic test based on specific amplification of the 16S rRNA gene of Mi. This reaction, designed Multi-species PCR-RFLP test, also amplifies the DNA of the pathogenic avian mycoplasmas M. gallisepticum (Mg) and M. synoviae (Ms). This test detects DNA equivalent to about 300 cfu Mi or either of the other two target mycoplasmas, individually or in mixed infection. It is a quick test, applicable to a wide variety of clinical samples, such as allantoic fluid or tracheal or cloacal swab suspensions. Differential diagnosis is carried out by gel electro-phoresis of the PCR amplicon digested with selected restriction enzymes (Restriction Fragment Length Polymorphism). This can also be readily accomplished by using a simple Dot-Blot hybridization assay with digoxigenin-labeled oligonucleotide probes reacting specifically with unique Mi, Mg or Ms sequences in the PCR amplicon. The PCR/OLIGO test increased sensitivity by at least 10-fold with a capacity for rapid testing of large numbers of samples. Experimental infection trials were carried out to evaluate the diagnostic tools and to study pathogenesis of Mi infection. Field studies and experimental infection of embryonated eggs indicated both synergistic and competitive interaction of mycoplasma pathogens in mixed infection. The value of the PCR diagnostic tests for following the time course of egg transmission was shown. A workable serological test (Dot Immunobinding Assay) was also developed but there was no clear-cut evidence that infected turkeys develop an immune response. Typing of a wide spectrum of Mi field isolates by a variety of gene-based molecular techniques indicated a higher degree of genetic homogeneity than predicted on the basis of the phenotypic variability. All known strains of Mi were detected by the method developed. Together with an M. meleagridis-PCR test based on the same gene, the Multi-species PCR test is a highly valuable tool for diagnosis of pathogenic mycoplasmas in single or mixed infection. The further application of this rapid and specific test as a part of Mi and overall mycoplasma control programs will be dependent on developments in the turkey industry.

Review question / Objective: The aim of this review is to identify and catalog studies that have reported the impact of indirect effects in interventions targeting malaria. Specific review questions are the following. 1. How many studies explicitly reported indirect effects? a. Have the number of publications increased in recent years? 2. What methodologies were employed by these studies to estimate the indirect effects? 3. Which terminologies were used to describe indirect effects? Background: Malaria is still a major health problem, particularly in sub-Saharan Africa, where 98% of global malaria mortality occurs. According to World Malaria Report 2022, the estimated case incidence was 229.4 per 1000 population in the African Region in 2021. Although the morbidity and mortality of malaria continued to decline from the 2000s to 2015 owing to many investments and interventions, such as long-lasting insecticide-treated net, rapid diagnostic tests, and artemisinin-based combination therapy, progress has been stalled since 2015. Moreover, especially after 2020, it has been reported that malaria incidence and mortality have increased in many African countries due to disruptions to services during the COVID-19 pandemic.

Intraspecies identification (DNA "fingerprinting") of pathogenic avian mycoplasmas is a powerful tool for epidemiological studies and monitoring strain identity. However the only widely method available for Mycoplasma gallisepticum (MG) and M. synoviae (MS)wasrandom amplified polymorphic DNA (RAPD). This project aimed to develop alternative and supplementary typing methods that will overcome the major constraints of RAPD, such as the need for isolation of the organism in pure culture and the lack of reproducibility intrinsic in the method. Our strategy focussed on recognition of molecular markers enabling identification of MG and MS vaccine strains and, by extension, pathogenic potential of field isolates. Our first aim was to develop PCR-based systems which will allow amplification of specific targeted genes directly from clinical material. For this purpose we evaluated the degree of intraspecies heterogeneity in genes encoding variable surface antigens uniquely found in MG all of which are putative pathogenicity factors. Phylogenic analysis of targeted sequences of selected genes (pvpA, gapA, mgc2, and lp) was employed to determine the relationship among MG strains.. This method, designated gene targeted sequencing (GTS), was successfully employed to identify strains and to establish epidemiologically-linked strain clusters. Diagnostic PCR tests were designed and validated for each of the target genes, allowing amplification of specific nucleotide sequences from clinical samples. An mgc2-PCR-RFLP test was designed for rapid differential diagnosis of MG vaccine strains in Israel. Addressing other project goals, we used transposon mutagenesis and in vivo and in vitro models for pathogenicity to correlated specific changes in target genes with biological properties that may impact the course of infection. An innovative method for specific detection and typing of MS strains was based on the hemagglutinin-encoding gene vlhA, uniquely found in this species. In parallel, we evaluated the application of amplified fragment length polymorphism (AFLP) in avian mycoplasmas. AFLP is a highly discriminatory method that scans the entire genome using infrequent restriction site PCR. As a first step the method was found to be highly correlated with other DNA typing methods for MG species and strain differentiation. The method is highly reproducible and relatively rapid, although it is necessary to isolate the strain to be tested. Both AFLP and GTS are readily to amenable to computer-assisted analysis of similarity and construction of a data-base resource. The availability of improved and diverse tools will help realize the full potential of molecular typing of avian mycoplasmas as an integral and essential part of mycoplasma control programs.

Background Lung cancer is the number one cause of cancer death worldwide.(1) It is the fifth most commonly diagnosed cancer in Australia (12,741 cases diagnosed in 2018) and the leading cause of cancer death.(2) The number of years of potential life lost to lung cancer in Australia is estimated to be 58,450, similar to that of colorectal and breast cancer combined.(3) While tobacco control strategies are most effective for disease prevention in the general population, early detection via low dose computed tomography (LDCT) screening in high-risk populations is a viable option for detecting asymptomatic disease in current (13%) and former (24%) Australian smokers.(4) The purpose of this Evidence Check review is to identify and analyse existing and emerging evidence for LDCT lung cancer screening in high-risk individuals to guide future program and policy planning. Evidence Check questions This review aimed to address the following questions: 1. What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? 2. What is the evidence of potential harms from lung cancer screening for higher-risk individuals? 3. What are the main components of recent major lung cancer screening programs or trials? 4. What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Summary of methods The authors searched the peer-reviewed literature across three databases (MEDLINE, PsycINFO and Embase) for existing systematic reviews and original studies published between 1 January 2009 and 8 August 2019. Fifteen systematic reviews (of which 8 were contemporary) and 64 original publications met the inclusion criteria set across the four questions. Key findings Question 1: What is the evidence for the effectiveness of lung cancer screening for higher-risk individuals? There is sufficient evidence from systematic reviews and meta-analyses of combined (pooled) data from screening trials (of high-risk individuals) to indicate that LDCT examination is clinically effective in reducing lung cancer mortality. In 2011, the landmark National Lung Cancer Screening Trial (NLST, a large-scale randomised controlled trial [RCT] conducted in the US) reported a 20% (95% CI 6.8% – 26.7%; P=0.004) relative reduction in mortality among long-term heavy smokers over three rounds of annual screening. High-risk eligibility criteria was defined as people aged 55–74 years with a smoking history of ≥30 pack-years (years in which a smoker has consumed 20-plus cigarettes each day) and, for former smokers, ≥30 pack-years and have quit within the past 15 years.(5) All-cause mortality was reduced by 6.7% (95% CI, 1.2% – 13.6%; P=0.02). Initial data from the second landmark RCT, the NEderlands-Leuvens Longkanker Screenings ONderzoek (known as the NELSON trial), have found an even greater reduction of 26% (95% CI, 9% – 41%) in lung cancer mortality, with full trial results yet to be published.(6, 7) Pooled analyses, including several smaller-scale European LDCT screening trials insufficiently powered in their own right, collectively demonstrate a statistically significant reduction in lung cancer mortality (RR 0.82, 95% CI 0.73–0.91).(8) Despite the reduction in all-cause mortality found in the NLST, pooled analyses of seven trials found no statistically significant difference in all-cause mortality (RR 0.95, 95% CI 0.90–1.00).(8) However, cancer-specific mortality is currently the most relevant outcome in cancer screening trials. These seven trials demonstrated a significantly greater proportion of early stage cancers in LDCT groups compared with controls (RR 2.08, 95% CI 1.43–3.03). Thus, when considering results across mortality outcomes and early stage cancers diagnosed, LDCT screening is considered to be clinically effective. Question 2: What is the evidence of potential harms from lung cancer screening for higher-risk individuals? The harms of LDCT lung cancer screening include false positive tests and the consequences of unnecessary invasive follow-up procedures for conditions that are eventually diagnosed as benign. While LDCT screening leads to an increased frequency of invasive procedures, it does not result in greater mortality soon after an invasive procedure (in trial settings when compared with the control arm).(8) Overdiagnosis, exposure to radiation, psychological distress and an impact on quality of life are other known harms. Systematic review evidence indicates the benefits of LDCT screening are likely to outweigh the harms. The potential harms are likely to be reduced as refinements are made to LDCT screening protocols through: i) the application of risk predication models (e.g. the PLCOm2012), which enable a more accurate selection of the high-risk population through the use of specific criteria (beyond age and smoking history); ii) the use of nodule management algorithms (e.g. Lung-RADS, PanCan), which assist in the diagnostic evaluation of screen-detected nodules and cancers (e.g. more precise volumetric assessment of nodules); and, iii) more judicious selection of patients for invasive procedures. Recent evidence suggests a positive LDCT result may transiently increase psychological distress but does not have long-term adverse effects on psychological distress or health-related quality of life (HRQoL). With regards to smoking cessation, there is no evidence to suggest screening participation invokes a false sense of assurance in smokers, nor a reduction in motivation to quit. The NELSON and Danish trials found no difference in smoking cessation rates between LDCT screening and control groups. Higher net cessation rates, compared with general population, suggest those who participate in screening trials may already be motivated to quit. Question 3: What are the main components of recent major lung cancer screening programs or trials? There are no systematic reviews that capture the main components of recent major lung cancer screening trials and programs. We extracted evidence from original studies and clinical guidance documents and organised this into key groups to form a concise set of components for potential implementation of a national lung cancer screening program in Australia: 1. Identifying the high-risk population: recruitment, eligibility, selection and referral 2. Educating the public, people at high risk and healthcare providers; this includes creating awareness of lung cancer, the benefits and harms of LDCT screening, and shared decision-making 3. Components necessary for health services to deliver a screening program: a. Planning phase: e.g. human resources to coordinate the program, electronic data systems that integrate medical records information and link to an established national registry b. Implementation phase: e.g. human and technological resources required to conduct LDCT examinations, interpretation of reports and communication of results to participants c. Monitoring and evaluation phase: e.g. monitoring outcomes across patients, radiological reporting, compliance with established standards and a quality assurance program 4. Data reporting and research, e.g. audit and feedback to multidisciplinary teams, reporting outcomes to enhance international research into LDCT screening 5. Incorporation of smoking cessation interventions, e.g. specific programs designed for LDCT screening or referral to existing community or hospital-based services that deliver cessation interventions. Most original studies are single-institution evaluations that contain descriptive data about the processes required to establish and implement a high-risk population-based screening program. Across all studies there is a consistent message as to the challenges and complexities of establishing LDCT screening programs to attract people at high risk who will receive the greatest benefits from participation. With regards to smoking cessation, evidence from one systematic review indicates the optimal strategy for incorporating smoking cessation interventions into a LDCT screening program is unclear. There is widespread agreement that LDCT screening attendance presents a ‘teachable moment’ for cessation advice, especially among those people who receive a positive scan result. Smoking cessation is an area of significant research investment; for instance, eight US-based clinical trials are now underway that aim to address how best to design and deliver cessation programs within large-scale LDCT screening programs.(9) Question 4: What is the cost-effectiveness of lung cancer screening programs (include studies of cost–utility)? Assessing the value or cost-effectiveness of LDCT screening involves a complex interplay of factors including data on effectiveness and costs, and institutional context. A key input is data about the effectiveness of potential and current screening programs with respect to case detection, and the likely outcomes of treating those cases sooner (in the presence of LDCT screening) as opposed to later (in the absence of LDCT screening). Evidence about the cost-effectiveness of LDCT screening programs has been summarised in two systematic reviews. We identified a further 13 studies—five modelling studies, one discrete choice experiment and seven articles—that used a variety of methods to assess cost-effectiveness. Three modelling studies indicated LDCT screening was cost-effective in the settings of the US and Europe. Two studies—one from Australia and one from New Zealand—reported LDCT screening would not be cost-effective using NLST-like protocols. We anticipate that, following the full publication of the NELSON trial, cost-effectiveness studies will likely be updated with new data that reduce uncertainty about factors that influence modelling outcomes, including the findings of indeterminate nodules. Gaps in the evidence There is a large and accessible body of evidence as to the effectiveness (Q1) and harms (Q2) of LDCT screening for lung cancer. Nevertheless, there are significant gaps in the evidence about the program components that are required to implement an effective LDCT screening program (Q3). Questions about LDCT screening acceptability and feasibility were not explicitly included in the scope. However, as the evidence is based primarily on US programs and UK pilot studies, the relevance to the local setting requires careful consideration. The Queensland Lung Cancer Screening Study provides feasibility data about clinical aspects of LDCT screening but little about program design. The International Lung Screening Trial is still in the recruitment phase and findings are not yet available for inclusion in this Evidence Check. The Australian Population Based Screening Framework was developed to “inform decision-makers on the key issues to be considered when assessing potential screening programs in Australia”.(10) As the Framework is specific to population-based, rather than high-risk, screening programs, there is a lack of clarity about transferability of criteria. However, the Framework criteria do stipulate that a screening program must be acceptable to “important subgroups such as target participants who are from culturally and linguistically diverse backgrounds, Aboriginal and Torres Strait Islander people, people from disadvantaged groups and people with a disability”.(10) An extensive search of the literature highlighted that there is very little information about the acceptability of LDCT screening to these population groups in Australia. Yet they are part of the high-risk population.(10) There are also considerable gaps in the evidence about the cost-effectiveness of LDCT screening in different settings, including Australia. The evidence base in this area is rapidly evolving and is likely to include new data from the NELSON trial and incorporate data about the costs of targeted- and immuno-therapies as these treatments become more widely available in Australia.