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Cost-effectiveness of the faecal immunochemical test at a range of positivity thresholds compared with the guaiac faecal occult blood test in the NHS Bowel Cancer Screening Programme in England
  1. Jacqueline Murphy1,
  2. Stephen Halloran2,
  3. Alastair Gray1
  1. 1 Health Economics Research Centre, Nuffield Department of Population Health, University of Oxford, Oxford, UK
  2. 2 Faculty of Health and Medical Sciences, University of Surrey, Guildford, UK
  1. Correspondence to Jacqueline Murphy; jacqueline.murphy{at}


Objectives Through the National Health Service (NHS) Bowel Cancer Screening Programme (BCSP), men and women in England aged between 60 and 74 years are invited for colorectal cancer (CRC) screening every 2 years using the guaiac faecal occult blood test (gFOBT). The aim of this analysis was to estimate the cost–utility of the faecal immunochemical test for haemoglobin (FIT) compared with gFOBT for a cohort beginning screening aged 60 years at a range of FIT positivity thresholds.

Design We constructed a cohort-based Markov state transition model of CRC disease progression and screening. Screening uptake, detection, adverse event, mortality and cost data were taken from BCSP data and national sources, including a recent large pilot study of FIT screening in the BCSP.

Results Our results suggest that FIT is cost-effective compared with gFOBT at all thresholds, resulting in cost savings and quality-adjusted life years (QALYs) gained over a lifetime time horizon. FIT was cost-saving (p<0.001) and resulted in QALY gains of 0.014 (95% CI 0.012 to 0.017) at the base case threshold of 180 µg Hb/g faeces. Greater health gains and cost savings were achieved as the FIT threshold was decreased due to savings in cancer management costs. However, at lower thresholds, FIT was also associated with more colonoscopies (increasing from 32 additional colonoscopies per 1000 people invited for screening for FIT 180 µg Hb/g faeces to 421 additional colonoscopies per 1000 people invited for screening for FIT 20 µg Hb/g faeces over a 40-year time horizon). Parameter uncertainty had limited impact on the conclusions.

Conclusions This is the first published economic analysis of FIT screening in England using data directly comparing FIT with gFOBT in the NHS BSCP. These results for a cohort starting screening aged 60 years suggest that FIT is highly cost-effective at all thresholds considered. Further modelling is needed to estimate economic outcomes for screening across all age cohorts simultaneously.

  • screening
  • colorectal cancer
  • economic evaluation
  • decision modelling
  • cost-effectiveness
  • cost-utility

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  • Contributors JM conducted the analysis and drafted the manuscript. SH advised on the analysis and contributed to the manuscript. AG conceived the study, advised on the analysis and contributed to the manuscript. All authors approved the final version of the manuscript.

  • Funding This work was supported by a research grant from the UK National Screening Committee (Public Health England) and was conducted independently. The views expressed in the paper are those of the authors alone.

  • Competing interests AG reports grants from Public Health England during the conduct of the study and is a member of the United Kingdom National Screening Committee.

  • Provenance and peer review Not commissioned; externally peer reviewed.

  • Data sharing statement Further information on the model structure, parameters and sensitivity analyses are available in the supplementary information. Correlation matrices used for Cholesky decomposition to model the uncertainty around the natural history parameters are available from the authors upon request.

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