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Evaluating a positive fecal occult blood test with a double-contrast barium enema study, followed, if necessary, by colonoscopy, is the most cost-effective strategy for individuals at average risk. An alternative screening strategy for higher-risk individuals or for populations in which the frequency of adenomatous polyps is higher is to follow a positive fecal occult blood test directly with colonoscopy. Sensitivity analysis demonstrated that the superior cost- effectiveness of these two strategies compared with the other 11 modeled strategies is almost independent for reasonable alterations in test cost and for the sensitivities and spec ificities of the procecures. The major contributing factor to the diagnostic cost is the frequency of adenomatous polyps. 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