Cost-Effectiveness of Fecal Immunochemical Testing Alone vs Co-Testing With Helicobacter pylori Stool Antigen
Adding one-time Helicobacter pylori stool testing to routine stool blood testing improved projected health outcomes and saved costs in Taiwan.
*Cost-effectiveness model based on randomized trial; Level 2 (OCEBM).
Citation
Lee YC, Liu JH, Mülder DT, et al. Cost-Effectiveness of Fecal Immunochemical Testing Alone vs Co-Testing With Helicobacter pylori Stool Antigen. JAMA. 2026;336(1):35-46.
Background
Helicobacter pylori infection is a major preventable cause of stomach cancer. Taiwan tested whether adding a one-time stool test for this bacterium to an existing stool blood test program for colorectal cancer would be worth the added effort and cost.
Patients
A simulated Taiwanese cohort aged 50 to 80 years, informed by a pragmatic randomized trial of about 240,000 people invited to community screening. Results may not apply to low-risk populations.
Intervention
Invitation to one-time Helicobacter pylori stool antigen testing plus every-2-year fecal immunochemical stool blood testing.
Control
Invitation to fecal immunochemical stool blood testing alone, the existing colorectal cancer screening strategy.
Outcome
Incremental cost per quality-adjusted life-year gained, plus cancer deaths and net economic benefit.
Follow-up Period
30-year modeled lifetime horizon.
Results
| Outcome | Co-testing vs stool blood testing alone |
|---|---|
| Incremental cost-effectiveness ratio (primary outcome) | Cost-saving: $2,094 saved per quality-adjusted life-year gained |
| Stomach cancer mortality | 13.5% relative reduction; about 1 fewer death per 1,000 people |
| Quality-adjusted life-years | +0.0038 per person |
| Net monetary benefit | $135 per person |
| Return on investment | $5.08 in societal value per $1 invested |
The model used real-world invitation and adherence patterns. Helicobacter pylori prevalence was the main driver; from a United States cost perspective, co-testing became unfavorable when prevalence fell below 21.9%.
Limitations
This was a modeled economic projection, not 30-year observed follow-up. Antibiotic resistance effects and benefits for ulcer disease were not fully modeled. Generalizability is strongest for populations with moderate or high Helicobacter pylori and stomach cancer risk.
Funding
Taiwan government and university hospital funding; no major commercial bias noted.
Clinical Application
Consider co-testing where Helicobacter pylori prevalence is moderate or high and stool-based colorectal cancer screening infrastructure already exists.
Discussion
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In this Markov cost-effectiveness analysis informed by a pragmatic RCT, H pylori stool antigen co-testing plus FIT vs FIT alone reduced projected gastric cancer mortality by 13.5% and saved $8/person; given these model-based projections, how valid/applicable are the findings for changing screening practice outside Taiwan? In this article, co-testing with H pylori stool antigen plus FIT was described as “dominant” compared with FIT alone because it gained 0.0038 QALYs and saved about $8 per person. What does a dominant strategy mean in a cost-effectiveness analysis?