Hidden value of colon capsule endoscopy: balancing patient preference, environmental impact, and cost-effectiveness

Letter to: Cost-effectiveness of colon capsule endoscopy in colorectal cancer screening: a modeling study Endoscopy 2025; 57(10): 1095-1105 DOI: 10.1055/a-2658-0960 10.1055/a-2658-0960 We read with interest the modeling study by de Jonge et al. evaluating the cost-effectiveness of colon capsule endoscopy (CCE) in colorectal cancer screening [ 1 ]. Using the MISCAN-Colon model, the authors concluded that CCE strategies are dominated by biennial fecal immunochemical test (FIT) and 10-yearly colonoscopy, largely due to high CCE unit costs (€600) and similar long-term outcomes to FIT. Although the conclusion supports the modeling assumptions and is in line with previous studies [ 2 ], we caution against overgeneralizing to all settings. The threshold analysis showed that CCE could be cost-effective at lower costs (e.g. €425 for biennial screening; prices are declining). Adherence assumptions are also critical. The sensitivity analyses assumed 25%–75% uptake, but recent trials show stronger patient preference for CCE over colonoscopy (45.8% vs. 11.4%) [ 3 ], with acceptability rivaling or exceeding FIT due to its non-invasive nature and potential reach of underserved communities. If CCE achieved FIT-like adherence (~75%) rather than colonoscopy-like adherence (~25%), it could yield substantially greater population-level benefits. Importantly, the model treats adherence as a static probability, yet real-world uptake is heterogeneous. Studies from Pioche et al. suggest CCE uptake is not a simple substitution for FIT or colonoscopy [ 4 ]; it may uniquely appeal to niche groups who decline colonoscopy for sociocultural reasons [ 5 ]. Explicitly segmenting FIT acceptors, FIT refusers who accept CCE, and colonoscopy acceptors/refusers would allow more realistic modeling of the incremental reach of CCE. The choice of a fixed willingness-to-pay threshold of €20 000 per quality-adjusted life year (QALY) gained may also be overly conservative. In the UK, National Institute for Health and Care Excellence considers values between £20 000 and £30 000 per additional QALY gained to represent good value for money [ 6 ]. Additionally, CCE has a role in capacity-constrained settings or for individuals who decline colonoscopy. Moreover, there is an environmental impact: the eCO 2 value per patient of CCE is half that of colonoscopy, at 2.9 vs. 5.6 kg [ 7 ]. Artificial intelligence-driven efficiencies with extended post-negative surveillance intervals (5–10 years rather than the modeled 2–3 years), together with patient preferences and environmental benefits, may yet prove CCE to be a cost-effective modality within colorectal cancer screening programs. Publication History Article published online: 27 November 2025 © 2025. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany