Estimating the frequency of overdiagnosis due to cancer screening is not a simple task, because overdiagnosis is almost never observable. Since we treat most cancers and their precursors, we rarely get to follow a tumor over its natural course and learn whether that tumor would have persisted as an indolent lesion, spontaneously regressed, or progressed to the point of producing symptoms.
To accurately assess the frequency of overdiagnosis, we need to really understand disease natural history. And this is a hard problem. In fact, one of the greatest controversies in the debate about overdiagnosis is how best to estimate this elusive quantity.
In this issue of JGIM, Zahl et al.1 comment on this controversy. To summarize, there are two main camps.2 One recognizes that overdiagnosis is a result of disease natural history that cannot be observed. Therefore, this camp uses statistical models to infer the most plausible underlying natural history. In a sense, this work uses observed data to ma ...
- Zahl PH, Jorgensen KJ, Gotzsche CO. Lead-time models should not be used to estimate overdiagnosis in cancer screening. J Gen Intern Med doi:10.1007/s11606-014-2812.2.
- Etzioni R, Gulati R, Mallinger L, Mandelblatt J. Influence of study features and methods on overdiagnosis estimates in breast and prostate cancer screening. Ann Intern Med 2013;158:831–8. PMC: 3733533.
- Biesheuvel C, Barratt A, Howard K, Houssami N, Irwig L. Effects of study methods and biases on estimates of invasive breast cancer over detection with mammography screening: a systematic review. Lancet Oncol 2007;8:1129–38. PMC.
- Duffy SW, Parmar D. Overdiagnosis in breast cancer screening: the importance of length of observation period and lead time. Breast Cancer Res 2013;15:R41. PMC: 3706885.
- Miller AB, Wall C, Baines CJ, Sun P, To T, Narod SA. Twenty-five year follow-up for breast cancer incidence and mortality of the Canadian National Breast Screening Study: randomized screening trial. BMJ 2014;348:g366. PMC: 3921437.
- Bleyer A, Welch HG. Effect of three decades of screening mammography on breast-cancer incidence. N Engl J Med 2012;367:1998–2005. PMC.
- Duffy SW, Lynge E, Jonsson H, Ayyaz S, Olsen AH. Complexities in the estimation of overdiagnosis in breast cancer screening. Br J Cancer 2008;99:1176–8. PMC.
- Zelen M, Feinleib M. On the theory of screening for chronic diseases. Biometrika 1969;56:601–14. PMC.
- Pinsky PF. Estimation and prediction for cancer screening models using deconvolution and smoothing. Biometrics 2001;57:389–95. PMC.
- De Gruttola V, Lagakos SW. Analysis of doubly-censored survival data, with application to AIDS. Biometrics 1989;45:1–11. PMC.
- Vink MA, Bogaards JA, van Kemenade FJ, de Melker HE, Meijer CJ, Berkhof J. Clinical progression of high-grade cervical intraepithelial neoplasia: estimating the time to preclinical cervical cancer from doubly censored national registry data. Am J Epidemiol 2013;178:1161–9. PMC.
- Fryback DG, Stout NK, Rosenberg MA, Trentham-Dietz A, Kuruchittham V, Remington PL. The Wisconsin Breast Cancer Epidemiology Simulation Model. J Natl Cancer Inst Monogr 2006:37–47. PMC.
- Seigneurin A, Francois O, Labarere J, Oudeville P, Monlong J, Colonna M. Overdiagnosis from non-progressive cancer detected by screening mammography: stochastic simulation study with calibration to population based registry data. BMJ 2011;343:d7017. PMC: 3222945.
- Zahl PH, Gotzsche PC, Maehlen J. Natural history of breast cancers detected in the Swedish mammography screening programme: a cohort study. Lancet Oncol 2011;12:1118–24. PMC.
- Zahl PH, Maehlen J, Welch HG. The natural history of invasive breast cancers detected by screening mammography. Arch Intern Med 2008;168:2311–6. PMC.
- Oversimplifying Overdiagnosis
Journal of General Internal Medicine
Volume 29, Issue 9 , pp 1218-1220
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