What is the most cost-effective CRC screening strategy in Asians?

Faecal immunochemical test (FIT) positive result followed by artificial intelligence (AI)–assisted colonoscopy represents the most cost-effective colorectal cancer (CRC) screening strategy in an Asian population, according to a study from the Chinese University of Hong Kong (CUHK).

Early colonoscopy screening can effectively reduce both the incidence of and mortality associated with CRC. [N Engl J Med 2022;387:1547-556] However, the sensitivity of conventional colonoscopy is limited by performing physicians’ level of experience, which can be mitigated by employing AI-assisted colonoscopy, as it has been shown to improve polyp and adenoma detection rates. [ANZ Journal of Surgery 2002:72:89-91; EClinicalMedicine 2023;doi:10.1016/j.eclinm.2023.102341]

“We aimed to conduct a comparative cost-effectiveness analysis [CEA] of AI-assisted colonoscopy, both as a primary and a secondary screening test within population-based CRC screening programmes, and compare it with FIT and conventional colonoscopy,” stated the researchers. [J Med Internet Res 2025;doi:10.2196/67762]

How much does screening save?

The study modelled a hypothetical population of 100,000 average-risk individuals aged 50 years, consistent with current clinical practice in Asia, where screening typically begins at the age of 50 years (eg, Hong Kong, China, South Korea). The outcomes of no screening, positive FIT result followed by conventional colonoscopy (FIT + cCS), positive FIT result followed by AI-assisted colonoscopy (FIT + AI-CS), direct conventional colonoscopy (cCS), and direct AI-assisted colonoscopy (AI-CS) were calculated based on assumptions from previous clinical studies conducted in Asian populations.

In the absence of screening, a cohort of average-risk participants aged 50 years would have 3,233 cases of CRC and a loss of 5,635 cancer-related life years. Screening using FIT + cCS, FIT + AI-CS, cCS, and cCS would prevent 3.7, 4.1, 41.9, and 46.4 percent of CRC cases, respectively. In addition, since treatment cost for advanced-stage CRC (stages III and IV) is substantially higher, early detection through screening would reduce both cancer mortality and treatment expenditures.

“Screening with direct cCS and AI-CS resulted in more life years saved and greater mortality reduction than FIT-based strategies, but at a higher cost,” noted the researchers. Compared with no screening, the incremental cost-effectiveness ratios (ICERs) of FIT + cCS, FIT + AI-CS, cCS, and AI-CS were USD 138,539, USD 122,539, USD 203,929, and USD 180,444, respectively. Therefore, FIT + AI-CS emerged as the most cost-effective strategy for CRC screening and prevention.

Of note, compared with FIT + cCS, FIT + AI-CS resulted in fewer cancer-related life years lost (5,355 vs 5,327 years), more life years saved (280 vs 308 years), and a lower total cost per life year saved (USD 944,008 vs 854,367).

Hong Kong perspective

In 2024, approximately 2.8 million individuals in Hong Kong were 50–74 years of age. “Our findings indicate that the FIT + AI-CS screening strategy could potentially prevent an additional 4,120 CRC cases and save 7,245 more life years compared with cCS. Furthermore, the total cost per life year saved could be reduced by approximately USD 927,000 vs cCS. FIT + AI-CS appears to be the most cost-effective CRC screening strategy with a better balance between cost and life years saved in Hong Kong,” concluded the researchers.