Circulating Thioredoxin 1 as an Adjunct to Mammography for Breast Cancer Detection: A Multicenter Clinical Validation Study.

Background/Objectives: Mammography remains central to breast cancer diagnosis, yet clinically meaningful uncertainty persists in women with dense breasts and in patients with very small lesions or indeterminate imaging findings. We evaluated whether circulating thioredoxin 1 (Trx1) could provide biological information that complements imaging-based assessment. Methods: This multicenter clinical validation study evaluated circulating Trx1 in 1901 serum samples across four predefined cohorts. Diagnostic performance was assessed using receiver operating characteristic (ROC) and precision-recall analyses, together with evaluation of integration with mammographic assessment and decision curve analysis (DCA). A predefined Trx1 cutoff established in prior clinical investigations was applied. Results: Circulating Trx1 concentrations were significantly elevated in breast cancer compared with controls (p < 0.001). Trx1 showed excellent diagnostic discrimination (AUC 0.985; 95% CI, 0.974-0.996), with sensitivity and specificity of 96.4% and 97.3%, respectively. Diagnostic performance was consistent across disease stages, tumor-size categories, molecular subtypes, mammographic categories, and breast-density groups. Trx1 sensitivity remained high in dense breasts (98.9% in BI-RADS density grades C/D), whereas mammographic sensitivity was substantially lower (67.0%). Integration of Trx1 with mammographic assessment improved diagnostic discrimination (AUC 0.980) and provided greater net benefit in decision curve analysis, particularly among women with low-suspicion or indeterminate imaging findings. Conclusions: Circulating Trx1 demonstrated robust diagnostic performance across disease stages, tumor-size categories, and clinically relevant patient subgroups while providing biologically independent information that complements mammographic assessment. Although this retrospective multicenter study requires prospective validation in independent diagnostic populations, Trx1 may serve as a clinically useful adjunct to imaging-based breast cancer evaluation, particularly in diagnostically uncertain settings.