Colon capsule endoscopy and cost-effectiveness across colorectal care: a valuable filter, but a poor universal substitute

Colon capsule endoscopy (CCE) is a patient-friendly, minimally invasive alternative to conventional colonoscopy, but its value depends on pathway performance rather than diagnostic accuracy alone. This narrative review examines the cost-effectiveness of CCE across colorectal cancer screening, symptomatic investigation, incomplete colonoscopy, post-polypectomy surveillance, inflammatory bowel disease monitoring, and AI-supported implementation. Targeted literature searches were performed in PubMed and official guidance sources through 6 July 2026. Across broad screening populations, CCE is not yet cost-effective compared with biennial faecal immunochemical testing (FIT) or 10-yearly colonoscopy; contemporary Dutch MISCAN modelling found all CCE screening strategies dominated at full adherence, largely because unit cost and follow-up colonoscopy burden remained high. The dominant economic problem is pathway duplication: a 2025 meta-analysis found a pooled follow-up endoscopy rate of 42%, and contemporary UK/Scottish service data showed that about half of patients required further optical endoscopy or sigmoidoscopy. CCE may offer conditional value after incomplete colonoscopy, in lower-risk symptomatic triage, and in carefully selected surveillance pathways where a negative or low-risk capsule result may avoid, defer, or focus colonoscopy. Evidence from Crohn’s disease and ulcerative colitis monitoring is encouraging but should not be extrapolated uncritically to colorectal cancer screening or dysplasia surveillance, where biopsy and therapy remain decisive. AI-assisted CCE may reduce reading time and improve polyp detection, but robust lifetime cost-effectiveness models are still needed. The current evidence supports CCE as a pathway-dependent filter, not a universal substitute for colonoscopy.