Cost-benefit analysis of biopsy methods for suspicious mammographic lesions; discussion 994-5

Reliable Biomarkers to Identify New and Recurrent Cancer

Breast cancer is the most frequent cancer detected throughout both the developing and the developed world. Its incidence is on the rise in the developing world. Great strides have been made in developing biomarkers to guide therapy for women diagnosed with breast cancer. Far fewer advances have occurred with biomarker development for the early diagnosis of breast cancer. Standard screening for new and recurrent breast cancer involves clinical breast exam and breast imaging. There are no Food and Drug Administration (FDA) approved noninvasive body fluid tests for the early detection of new or recurrent breast cancer. Promising biomarker approaches include multianalyte testing of tissue for individuals diagnosed with breast cancer and body fluid analysis for both at risk women and to monitor individuals after treatment.

Serum microRNA profiling and breast cancer risk: the use of miR-484/191 as endogenous controls

It has been demonstrated that there are abundant stable microRNAs (miRNAs) in plasma/serum, which can be detected and are potentially disease specific. However, the lack of suitable endogenous controls for serum miRNA detection is the restriction for the widely usage of this kind of biomarkers and for the between-laboratory comparison of the findings. We first systematically screened for endogenous control miRNAs (ECMs) by testing 10 pooling samples (using both Solexa sequencing and TaqMan low density array) and 50 individual samples (using quantitative reverse transcription-PCR) of different cancer traits and healthy controls. Then we assessed serum miRNAs used as potential biomarkers for breast cancer risk prediction based on a two-stage case-control analysis, including 48 breast cancer patients and 48 controls for the discovery stage and 76 breast cancer patients and 76 controls for validation. We identified two candidate ECMs (miRNA-191 and miRNA-484). Normalized by the two ECMs, we found four miRNAs (miR-16, miR-25, miR-222 and miR-324-3p) that were consistently differentially expressed between breast cancer cases and controls. The area under the receiver operating characteristic curve is 0.954 for the four-miRNA signature in the discovery stage (sensitivity = 0.917 and specificity = 0.896) and 0.928 in the validation stage (sensitivity = 0.921 and specificity = 0.934). In conclusion, the four-miRNA signature from serum may serve as a non-invasive prediction biomarker for breast cancer. Furthermore, we proposed the combination of miRNA-484 and miRNA-191 as endogenous control for serum miRNA detection, at least for most common cancers.

Presurgical localization of breast abnormalities: an overview and analysis of 202 cases

The purpose of this study was to analyze cases undergoing imaging guided localization prior to surgical excisional biopsy of abnormalities in the breast and to describe the methodology utilized to perform such presurgical localization procedures. Presurgical localization of non palpable breast abnormalities is a simple, safe and effective procedure; it is now used more selectively for this indication due to availability of minimally invasive percutaneous biopsy procedures that can be performed under ultrasound or stereotactic guidance.

Identification of a beta-casein-like peptide in breast nipple aspirate fluid that is associated with breast cancer

AIMS

Nipple aspirate fluid was collected prospectively from women scheduled for diagnostic breast surgery in order to determine protein masses associated with breast cancer, subsets of women with a unique proteomic profile and a breast cancer predictive model.

MATERIALS & METHODS

Breast nipple aspirate fluid was collected preoperatively in 163 breasts from 125 women and analyzed for changes in cell morphology and by SELDI-TOF mass spectrometry over approximately a 44 kDa range (1.5-45 kDa) using IMAC30, CM10 and Q10 ProteinChips.

RESULTS

Considering all samples, 16 protein masses were associated with the presence of cancer, the most discriminating being 3592, 6570/6580 and 15870 Da. Excluding women with pathologic nipple discharge or those with a papilloma identified an additional protein of 6383 Da. The best cancer detection models included Breast Imaging Reporting and Data System, age, and either the 4262 (best sensitivity: >87%) or 3592 (best specificity: >94%) peak. MALDI-TOF mass spectrometry demonstrated the 3592 peak, which was most discriminating in many of our cancer prediction models, to be a beta-casein-like peptide.

CONCLUSION

Differential nipple aspirate fluid proteomic expression exists between women with/without breast cancer. The most discriminating protein identified is a beta-casein-like peptide not previously described. Combining proteomic and clinical information, which are available before surgery, optimizes the prediction of which women have breast cancer.

Nipple aspirate fluid and ductoscopy to detect breast cancer

We prospectively performed cytologic assessment and image analysis (IA) on matched nipple aspirate fluid (NAF) and mammary ductoscopy (MD) specimens to determine (1) the accuracy of these methods in cancer detection and (2) whether the two collection methods provide complementary information.NAF and MD specimens were collected from 84 breasts from 75 women (nine bilateral samples) who underwent breast surgery. Cytologic evaluation was performed on all samples. IA was performed on slides with sufficient epithelial cells.Cytologic evaluation proved more accurate in patients without pathologic spontaneous nipple discharge (PND) than those with PND, mainly because of the potential false positive diagnosis in the latter. While the sensitivity of NAF and MD cytology was low (10% and 14%, respectively), both were 100% specific in cancer detection in the non-PND cohort. Combining NAF and MD cytology information improved sensitivity (24%) without sacrificing specificity. Similar to cytology, IA was more accurate in patients without PND having high specificity (100% for aneuploid IA), but relatively low sensitivity (36%). Combining NAF and MD cytology with aneuploid IA improved the sensitivity (45%) while maintaining high specificity (100%). The best predictive model was positive NAF cytology and/or MD cytology combined with IA aneuploidy, which resulted in 55% sensitivity and 100% specificity in breast cancer detection.Cytologic evaluation and IA of NAF and MD specimens are complementary. The presence of atypical cells arising from an intraductal papilloma in ductoscopic specimens is a potential source of false positive diagnosis in patients with nipple discharge.

Circulating microRNAs in breast cancer and healthy subjects

Background

It has been demonstrated that extracellular mRNA can be detected in the circulation. Our hypothesis was that circulating miRNAs are also present and differentially expressed in the serum of breast cancer patients compared to controls.

Findings

We measured miRNA in the serum of samples with and without the addition of miRNA prior to analysis. To test our RNA extraction efficiency, we spiked-in serial dilutions of single-strand C elegens miR-39 (cel-miR-39) and human miR-145 (has-miR-145) into goat serum and a 10 year old human serum specimen. We next analyzed miR-16, -145, and -155 in archived serum specimens from 21 participants, 13 of whom did and 8 of whom did not have breast cancer. We were able to detect the miRNAs from all the serum samples to which the miRNAs had been added. We were also able to detect endogenous miR-16, -145, and -155 in all serum samples. While the expression of all three miRNAs was similar in samples from healthy women compared to those with breast cancer, women with progesterone receptor (PR, p = 0.016) positive tumors had higher miR-155 expression than tumors that were negative for these receptors.

Conclusion

1) RNA species can be detected in archived serum; 2) miR-155 may be differentially expressed in the serum of women with hormone sensitive compared to women with hormone insensitive breast cancer. Screening serum for miRNAs that predict the presence of breast cancer is feasible, and may be useful for breast cancer detection.

Increased shedding of soluble fragments of P-cadherin in nipple aspirate fluids from women with breast cancer

Breast cancer, a worldwide disease with increasing incidence, develops from ductal/lobular epithelium. Nipple aspirate fluid (NAF), secreted from the breast ducts and lobules, can be analyzed to assess breast metabolic activity. P-cadherin is frequently over-expressed in high-grade invasive breast carcinomas and has been reported to be an enhancer of migration and invasion of breast cancer cells, being correlated with tumor aggressiveness. The present study analyzed the soluble fragment of P-cadherin in milk, NAF and matched plasma samples of healthy subjects and in women with precancer conditions and breast cancer. Soluble P-cadherin was detected in all plasma and milk samples, and in about 31.3% of NAF samples. The lowest levels of soluble P-cadherin were found in plasma, with no significant difference among NoCancer, PreCancer and Cancer patients. The highest concentration of soluble P-cadherin was detected in milk collected during the first trimester of lactation, significantly with respect to all NAF samples. There were significantly higher levels of soluble P-cadherin in NAF from Cancer patients than those in women with NoCancer and PreCancer (P < 0.0001). Although no significant difference was found between in situ and invasive breast cancer, soluble P-cadherin levels were found at high concentrations in c-erbB-2-positive tumors, showing a positive correlation with disease stage grouping and tumor grade, and an inverse relationship with estrogen/progesterone receptor status. High levels of the soluble fragment of P-cadherin in Cancer NAF suggest its possible release via proteolytic processing, favoring cancer cell detachment from breast duct, and suggesting that measuring soluble P-cadherin in NAF may improve the identification of women with increased breast cancer risk.

Increased expression of the inflammatory protein YKL-40 in precancers of the breast

Serum levels of YKL-40 have been associated with inflammatory diseases and breast cancer. Our purpose was to determine if YKL-40 in breast tissue, nipple aspirate fluid (NAF) and serum is (i) concentrated in NAF compared to matched serum, (ii) increased in the NAF, serum or tissue of women with biopsy proven precancer or cancer compared to healthy women and (iii) influenced by menopausal status. 118 women (61 healthy subjects, 10 with precancer and 47 with breast cancer) aged 17-95 years provided NAF with or without serum samples for analysis. Matched tissue was analyzed from a subset of subjects who underwent breast biopsy. All NAF and serum samples had detectable levels of YKL-40. Median YKL-40 levels for the entire cohort were 683 fold higher in NAF than serum. Premenopausal subjects had higher NAF and lower serum levels of YKL-40 than postmenopausal subjects. YKL-40 levels in NAF but not serum were higher in women with precancer (atypical hyperplasia and lobular carcinoma in situ) than in either healthy subjects (p = 0.025) or subjects with breast cancer (p = 0.015). In women with precancer, YKL-40 distribution in tissue correlated with YKL serum level (p = 0.043). YKL-40 is concentrated in NAF, with the highest concentrations in premenopausal women. NAF levels of YKL-40 are significantly higher in women with precancers than healthy subjects, suggesting that measuring YKL-40 in NAF may improve the identification of women at increased breast cancer risk.

Receptor-mediated internalization of chelator-PNA-peptide hybridization probes for radioimaging or magnetic resonance imaging of oncogene mRNAs in tumours

Early external detection of cancer gene activity might enable early treatment of cancer and might reduce cancer mortality. We hypothesized that oncogene mRNA overexpressed at thousands of copies per malignant cell in a zone of transformed cells could be imaged externally by scintigraphic imaging, PET (positron emission tomography) or MRI (magnetic resonance imaging) with PNA (peptide nucleic acid) hybridization probes that include chelators for metal cations and a cyclized peptide analogue of IGF-1 (insulin-like growth factor 1), D(Cys-Ser-Lys-Cys), to mediate internalization by IGF1R (IGF-1 receptor) overexpressed on cancer cells. We observed that human MCF7 breast cancer cells that overexpress IGF1R efficiently internalized fluorescein-chelator-PNA-D(Cys-Ser-Lys-Cys) to the cytoplasm, but not with D(Cys-Ala-Ala-Cys). Scintigraphic imaging of MCF7 xenografts in immunocompromised mice revealed that CCND1 and MYC [(99m)Tc]chelator-PNA-D(Cys-Ser-Lys-Cys) probes yielded xenograft. PET imaging with [(64)Cu]chelator-PNA-D(Cys-Ser-Lys-Cys) yielded stronger signals. Scintigraphic imaging of human AsPC1 pancreas cancer xenografts with [(99m)Tc]chelator-KRAS PNA-D(Cys-Ser-Lys-Cys) yielded strong xenograft signals. Stronger xenograft image intensities were obtained by PET imaging of [(64)Cu]chelator-KRAS PNA-D(Cys-Ser-Lys-Cys). MRI required extension of chelator-polydiamidopropanoate dendrimers from the N-termini of the PNA probes to increase the number of contrast paramagnetic gadolinium (III) cations per probe. These results provide a basis for detection of oncogene activity in tissues from outside the body by hybridization with metal-chelator-PNA-peptides that are selectively internalized by cancer cells.

Association of Clinical and Pathologic Variables with Lumpectomy Surgical Margin Status after Preoperative Diagnosis or Excisional Biopsy of Invasive Breast Cancer

PURPOSE

To evaluate the impact of preoperative diagnosis in obtaining negative lumpectomy margins.

MATERIALS AND METHODS

Five hundred and thirty five patients who underwent breast conserving therapy for stage I/II cancer from 1971 to 1996 were included in this IRB-approved retrospective analysis. Three hundred and ninety five patients had a defined inked margin status after initial excision. The following factors were evaluated for correlation with margins at initial excision: age (< or >45), grade (3/1 or 2), family history (present/absent), histology (lobular/other), estrogen receptor (ER) status, presence of extensive intraductal carcinoma (EIC), presence of lymphovascular invasion (LVI), and biopsy type (excisional/preoperative).

RESULTS

Biopsy type (P < 0.0001), EIC (P = 0.002), ER status (P = 0.02), lobular histology (P = 0.02) and age (P = 0.02) were significantly correlated with initial margin status among the entire group. For patients who underwent preoperative diagnostic biopsy, 52% (35/67) had negative initial margins as compared to 29% (94/328) for excisional biopsy. Among patients who underwent preoperative biopsy, only lobular histology (P = 0.04) and LVI (P = 0.04) were related to initial margin status. The rate of re-excision was 34% for patients diagnosed preoperatively versus 61% with excisional biopsy (P < 0.0001). The percentage of patients with negative final margin status was similar with either core/needle or excisional biopsy (79 and 78%, respectively).

CONCLUSIONS

Preoperative diagnosis is the most significant predictor of initial margin status in patients undergoing breast conservation. Patients with lobular histology may require improved preoperative and/or intraoperative assessment to increase the rate of negative margins at initial excision.

Nipple aspirate fluid color is associated with breast cancer

BACKGROUND

Fluid can be non-invasively aspirated from the breast nipple (nipple aspirate fluid, NAF). NAF may have many colors, including clear, white, yellow, green, and red/brown. While bloody spontaneous nipple discharge has been linked with breast cancer, the association of NAF color with cancer is not established. Our hypothesis was that red/brown NAF color was associated with breast cancer. The purpose of this study was to assess (1) if red/brown NAF is associated with the presence and progression of breast cancer, (2) the influence of prior needle or surgical biopsy on NAF color, and (3) if an association between NAF color and breast cancer was found, to develop a cancer predictive model including NAF color and cytology, and clinical information.

METHODS

Specimens were obtained from 848 breasts between 1999 and 2004 after subjects enrolled in an IRB approved protocol to evaluate biologic markers of breast cancer. Cytologic evaluation was performed on Papanicolaou-stained cytospin preparations of NAF.

RESULTS

Red/brown NAF was associated with breast cancer when considering all samples (p<0.001) and samples from women who did not undergo recent surgery (p=0.005). Needle biopsy did not, but surgical biopsy did influence NAF color. For the 327 women with NAF collected from both breasts, there was a significant association between red/brown NAF color and the presence of breast cancer (p=0.005). Red/brown NAF was more common in breasts with ductal carcinoma in situ than atypical hyperplasia (p=0.008). The optimal model, included NAF color, cytology, and age, was 92% sensitive and 61% specific in predicting if a woman had breast cancer.

CONCLUSIONS

NAF color was associated with the presence of breast cancer and the progression from precancer to cancer in a population of women who presented to a breast cancer evaluation clinic. NAF color contributed to a highly predictive breast cancer detection model. Additional studies are warranted to determine the usefulness of NAF color in the assessment of women who present for breast cancer evaluation.

External imaging of CCND1, MYC, and KRAS oncogene mRNAs with tumor-targeted radionuclide-PNA-peptide chimeras

In 2005, breast cancer will kill approximately 40,410 women in the U.S., and pancreatic cancer will kill approximately 31,800 men and women in the U.S. Clinical examination and mammography, the currently accepted breast cancer screening methods, miss almost half of breast cancers in women younger than 40 years, approximately one-quarter of cancers in women aged 40-49 years, and one-fifth of cancers in women over 50 years old. Pancreatic cancer progresses rapidly, with only 1% of patients surviving more than 5 years after diagnosis. However, if the disease is diagnosed when it is localized, the 5-year survival is approximately 20%. It would be beneficial to detect breast cancer and pancreatic cancer at the earliest possible stage, when multimodal therapy with surgery, radiotherapy, and chemotherapy have the greatest chance of prolonging survival. Human estrogen receptor-positive breast cancer cells typically display elevated levels of Myc protein due to overexpression of MYC mRNA, elevated cyclin D1 protein due to overexpression of CCND1 mRNA, and elevated insulin-like growth factor 1 receptor (IGF1R) due to overexpression of IGF1R mRNA. We hypothesized that scintigraphic detection of MYC or CCND1 peptide nucleic acid (PNA) probes with an IGF1 peptide loop on the C-terminus, and a Tc-99m-chelator peptide on the N-terminus, could measure levels of MYC or CCND1 mRNA noninvasively in human IGF1R-overexpressing MCF7 breast cancer xenografts in immunocompromised mice. Similarly, human pancreatic cancer cells typically display elevated levels of KRAS mRNA and elevated IGF1R. Hence, we also hypothesized that a KRAS Tc-99m-chelator PNA-peptide probe could detect overexpression of KRAS mRNA in pancreatic cancer xenografts by scintigraphic imaging, or by positron emission tomography (PET) with a KRAS Cu-64-chelator PNA-peptide. Human MCF7 breast cancer xenografts in immunocompromised mice were imaged scintigraphically 4-24 h after tail-vein administration of MYC or CCND1 Tc-99m-chelator PNA-peptides, but not after administration of mismatch controls. Similarly, human Panc-1 pancreatic cancer cells xenografts were imaged scintigraphically 4 and 24 h after tail-vein administration of a KRAS Tc-99m-chelator PNA-peptide, and AsPC1 xenografts were imaged by PET 4 and 24 h after tail-vein adminstration of a KRAS Cu-64-chelator PNA-peptide. The radioprobes distributed normally to the kidneys, livers, tumors, and other tissues. External molecular imaging of oncogene mRNAs in solid tumors with radiolabel-PNA-peptide chimeras might in the future provide additional genetic characterization of pre-invasive and invasive breast cancers.

Tumor-targeting peptide-PNA-peptide chimeras for imaging overexpressed oncogene mRNAs

We have optimized a method involving continuous solid phase synthesis of chelator-peptide-PNA-peptide probes in order to noninvasively image oncogene mRNAs overexpressed in tumors. The PNA (peptide nucleic acid) probes carry cyclized peptide ligand analogs specific for receptors overexpressed on malignant breast or colorectal cancer cells, and chelators to bind radioactive metal ions, or a fluorophore. In vivo scintigraphic imaging of MCF7 xenografts in immunocompromised mice indicated that CCND1 and MYC [99sTc] chelator-PNA-D (CSKC) probes concentrated in MCF7 cells up to 7 times more than the corresponding mismatch controls.

Positive predictive value of BI-RADS categorization in an Asian population

The Breast Imaging Reporting And Data System (BI-RADS) categorization of mammograms is useful in estimating the risk of malignancy, thereby guiding management decisions. However, in Asian women, in whom breast density is increased, the sensitivity of mammography is correspondingly lower. We sought to determine the positive predictive value of BI-RADS categorization for malignancy in our Asian population and, hence, its value in helping us to choose between the various modalities for breast biopsy. We retrospectively reviewed all patients with occult breast lesions detected on mammography or ultrasound who underwent needle-localization open breast biopsy (NLOB) in our institution over a 6-year period. There were 470 biopsies in 427 patients; 16% of lesions were malignant. The positive predictive value of BI-RADS 4 and 5 lesions for cancer was 0.27 and 0.84, respectively. While most BI-RADS 5 mass lesions were invasive cancers, the majority of calcifications in this category were in situ carcinomas. We conclude that BI-RADS remains useful in aiding decision-making for biopsy in our Asian population. Based on positive predictive values, we recommend percutaneous breast biopsy for initial evaluation of lesions categorized as BI-RADS 4 or less. For BI-RADS 5 lesions with microcalcifications, open surgical biopsy as a diagnostic and therapeutic procedure may be more appropriate. In the case of a BI-RADS 5 lesion associated with a mass, initial percutaneous biopsy may be useful for diagnosis, followed by a planned single-stage surgical procedure as necessary.

Proteomic analysis of nipple aspirate fluid using SELDI-TOF-MS

Proteomic analysis of body fluids, including breast nipple aspirate fluid (NAF), holds promise to aid in early cancer detection. We conducted a prospective trial that collected NAF from women scheduled for diagnostic breast surgery to determine 1) the consistency of proteomic results, 2) protein masses associated with breast cancer, 3) subsets of women with a unique proteomic profile and 4) a breast cancer predictive model. NAF was collected preoperatively in 114 women and analyzed by SELDI-TOF mass spectrometry over a 3-50 kDa range using H4, NP and SAX ProteinChips. For all 3 chips, the same protein peaks were detected over 90% of the time in duplicate samples. The overall coefficient of variation was < or = 0.17% for each chip for the internal standard and < or = 0.29% for the unknown proteins. Seven candidate protein ion masses frequently expressed in NAF were identified. Three (5,200-H4, p=.04, 11,880-H4, p=.07 and 13,880 Da-SAX, p=.03) were differentially expressed in women with/without breast cancer. Protein expression differed between women with/without pathologic nipple discharge (PND), but the 5,200, 11,880 and 13,880 proteins remained associated with breast cancer even if PND samples were excluded. Subset analysis identified differences in expression between benign disease and DCIS and between DCIS and invasive cancer for the 5,200 and 33,400 Da proteins. The best cancer detection model included age, parity and the 11,880 Da protein, and excluded women with PND. 1) NAF proteomic analysis using SELDI-TOF is reproducible with the same sample set across different platforms, 2) differential proteomic expression exists between women/without breast cancer and 3) combining proteomic and clinical information that are available before surgery optimizes the prediction of which women have breast cancer.

Is Stereotactic Large-Core Needle Biopsy Beneficial Prior to Surgical Treatment in BI-RADS 5 Lesions?

INTRODUCTION

Due to screening mammography, more nonpalpable mammographic lesions warrant histological evaluation. Stereotactic large-core needle biopsy (SLCNB) has been shown to be as effective in diagnosing these lesions as diagnostic surgical excision, and has become the preferred diagnostic procedure for most mammographic lesions. Since radiologically malignant BI-RADS 5 lesions are almost always carcinoma, some centers advocate prompt diagnostic surgical excision for these lesions instead of SLCNB. For some patients this diagnostic surgical intervention may serve as definitive treatment. We set out to find a subgroup of mammographic BI-RADS 5 lesions for which surgical biopsy might be preferable.

METHODS

Of 1644 consecutive nonpalpable lesions referred for SLCNB between April 1997 and May 2002, 238 were classified as BI-RADS 5. We assessed the number of carcinomas and the surgical interventions performed. Outcomes were compared between various types of mammographic lesions: density with calcifications, density without calcifications, and calcifications only. Different theoretical strategies for diagnostic work-up of BI-RADS 5 lesions were explored.

RESULTS

Carcinoma was found in 229/238 lesions (96%). Most mammographic densities were invasive cancer (97%), while calcifications only showed the highest risk for DCIS (51%). In our study (current practice) all lesions were scheduled to first undergo SLCNB. A scenario was proposed where all lesions with only a density would be scheduled directly for sentinel node biopsy (SNB) and tumour excision (n = 154; 65%), while other lesions would still be scheduled for SLCNB. When we compared this scenario to current practice, four out of 238 patients (< 2%) would be 'overtreated' with SNB.

CONCLUSIONS

Our findings confirm a high predictive value of malignancy for BI-RADS 5 lesions (96%). Surgical excision is therefore imperative for all BI-RADS 5 lesions, irrespective of SLCNB results. For BI-RADS 5 lesions presenting as mammographic densities only, we propose to consider surgical excision with SNB to be the first diagnostic and therapeutic procedure. SLCNB is preferred in all other cases.

Cost minimization study of image-guided core biopsy versus surgical excisional biopsy for women with abnormal mammograms

PURPOSE

To describe the clinical and economic consequences of image-guided core biopsy versus surgical excisional biopsy of mammographically identified breast lesions.

PATIENTS AND METHODS

Clinical and economic data were collected for 1121 patients undergoing core biopsies and 501 patients undergoing surgical biopsies between 1996 and 1998. Lesions were classified according to mammographic degree of suspicion and type of radiographic abnormality. Costs were measured from the societal perspective. A decision analytic model was constructed, with probabilistic sensitivity analysis.

RESULTS

Lesions diagnosed via core versus surgical biopsy were less likely to be masses (39% v 55%), less likely to be classified as high cancer suspicion (17% v 26%), and less likely to be treated with a single procedure (74% v 81%; P <.001 for each). Cancers diagnosed by a surgical biopsy were less likely to have had a single operative procedure (33% v 84%) and were associated with higher total costs whether mastectomy (US dollars 2775 v US dollars 1849) or lumpectomy (US dollars 2112 v US dollars 1365) was used. Sensitivity analysis showed core biopsy optimal in 95.4% of trials. Core biopsy was favored for low-suspicion lesions, calcifications, and masses, and overall for patients who underwent lumpectomy alone.

CONCLUSION

Image-guided core biopsy can be cost-saving compared with surgical biopsy, particularly when the mammographic abnormality is classified as low suspicion or consists of calcifications or masses. Moving to a policy in which core biopsy is the preferred approach in these settings has the potential to result in significant cost savings.