Economic value and clinical role of minimally invasive, biopsy‐based diagnostics in non‐small cell lung cancer

BACKGROUND: Precision oncology requires diagnostic sampling that delivers molecularly actionable material quickly and safely. In non-small cell lung cancer (NSCLC), core-needle biopsy (CNB) remains common. Yet fine-needle aspiration (FNA) has re-emerged with rapid on-site evaluation (ROSE), optimized cell blocks, and next-generation sequencing. The objective of this study was to compare the economic costs of FNA versus CNB with respect to an FNA-first with predefined CNB escalation strategy for NSCLC clinical pathways. METHOD: The authors synthesized evidence on diagnostic adequacy, complication rates, and molecular performance of cytology versus core tissue. A microcosting framework decomposed total diagnostic episode costs into sampling, processing, complications, and remedial procedures. This framework was applied to Sweden's Standardized Cancer Care Pathway for NSCLC using decision-tree modeling and sensitivity analyses. RESULTS: Modern cytology workflows with ROSE achieve a nondiagnostic sampling rate ≤6% and support programmed death-ligand 1 and broad next-generation sequencing with high mutation concordance to surgical specimens. Compared with CNB, FNA incurs fewer major complications and facilitates repeat sampling. In the Swedish illustration, an FNA-first pathway with ROSE reduced expected per-patient diagnostic cost by approximately 33% (7748 vs. 11,637 Swedish krona). The results were robust to ±50% variation in complication rates and ±5%-10% variation in adequacy. CONCLUSIONS: Reframing adequacy around molecular fitness and time to actionability supports FNA where ROSE exists, with codified, same-episode CNB escalation. This approach advances safety, capacity, and timeliness without compromising molecular yield. The authors provide a transferable cost-consequence model and implementation checklist for health systems. Local recalibration is required for absolute cost values, and multisite calibration is encouraged to establish generalizability across the different settings.