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

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Abstract 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.