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The fecal immunochemical test (FIT) is commonly used for colorectal cancer (CRC) screening. Despite demographic variations in stool hemoglobin concentrations, few data exist regarding optimal positivity thresholds by age and sex.To identify programmatic (multitest) FIT performance characteristics and optimal FIT quantitative hemoglobin positivity thresholds in a large, population-based, screening program.Retrospective cohort study.Kaiser Permanente Northern and Southern California.Adults aged 50 to 75 years who were eligible for screening and had baseline quantitative FIT results (2013 to 2014) and 2 years of follow-up. Nearly two thirds (411 241) had FIT screening in the previous 2 years.FIT programmatic sensitivity for CRC and number of positive test results per cancer case detected, overall and by age and sex.Of 640 859 persons who completed a baseline FIT and were followed for 2 years, 481 817 (75%) had at least 1 additional FIT and 1245 (0.19%) received a CRC diagnosis. Cancer detection (programmatic sensitivity) increased at lower positivity thresholds, from 822 in 1245 (66.0%) at 30 μg/g to 925 (74.3%) at 20 μg/g and 987 (79.3%) at 10 μg/g; the number of positive test results per cancer case detected increased from 43 at 30 μg/g to 52 at 20 μg/g and 85 at 10 μg/g. Reducing the positivity threshold from 20 to 15 μg/g would detect 3% more cancer cases and require 23% more colonoscopies. At the conventional FIT threshold of 20 μg/g, programmatic sensitivity decreased with increasing age (79.0%, 73.4%, and 68.9% for ages 50 to 59, 60 to 69, and 70 to 75 years, respectively; P = 0.009) and was higher in men than women (77.0% vs. 70.6%; P = 0.011).Information on advanced adenoma was lacking.Increased cancer detection at lower positivity thresholds is counterbalanced by substantial increases in positive tests. Tailored thresholds may provide screening benefits that are more equal among different demographic groups, depending on local resources.National Cancer Institute.