European Journal of Epidemiology

, Volume 29, Issue 9, pp 599–604 | Cite as

Diagnosing overdiagnosis: conceptual challenges and suggested solutions

  • Bjorn HofmannEmail author


Overdiagnosis is a fundamental challenge to modern health care [1]. It is claimed to be “the biggest problem posed by modern medicine” [2], leading to unnecessary suffering and significant costs [1]. In the USA it is estimated that it results in more than $200bn wasted on unnecessary treatment every year [3], and that 30 % of the health care spending is on ineffective measures [4, 5].

Many drivers of overdiagnosis have been identified (Fig.  1). The main challenges with overdiagnosis are: unnecessary diagnosis (including anxiety and reduced quality of life), unnecessary treatment (including harms and adverse side effects), allocation of scarce resources (including opportunity cost), professional integrity, and potential reduced trust in the health care services.


Common Definition Early Testing Health Care Spending False Negative Test False Positive Test Result 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.


Conflict of interest

I certify that there is no conflict of interest in relation to this manuscript, and there are no financial arrangements or arrangements with respect to the content of this manuscript with any companies or organizations. The manuscript is not published elsewhere.


  1. 1.
    Moynihan R, Doust J, Henry D. Preventing overdiagnosis: how to stop harming the healthy. BMJ. 2012;344:e3502. doi: 10.1136/bmj.e3502.PubMedCrossRefGoogle Scholar
  2. 2.
    Welch HG, Schwartz L, Woloshin S. Overdiagnosed : making people sick in the pursuit of health. Boston: Beacon Press; 2011.Google Scholar
  3. 3.
    Berwick DM, Hackbarth AD. Eliminating waste in US health care. JAMA. 2012;307(14):1513–6. doi: 10.1001/jama.2012.362.PubMedCrossRefGoogle Scholar
  4. 4.
    Bloche MG. Beyond the “R word”? Medicine’s new frugality. N Engl J Med. 2012;366(21):1951–3. doi: 10.1056/NEJMp1203521.PubMedCrossRefGoogle Scholar
  5. 5.
    Fisher ES, Wennberg DE, Stukel TA, Gottlieb DJ, Lucas FL, Pinder EL. The implications of regional variations in medicare spending. Part 2: health outcomes and satisfaction with care. Ann Intern Med. 2003;138(4):288–98.PubMedCrossRefGoogle Scholar
  6. 6.
    Puliti D, Zappa M, Miccinesi G, Falini P, Crocetti E, Paci E. An estimate of overdiagnosis 15 years after the start of mammographic screening in Florence. Eur J Cancer. 2009;45(18):3166–71. doi: 10.1016/j.ejca.2009.06.014.PubMedCrossRefGoogle Scholar
  7. 7.
    Jorgensen KJ, Zahl PH, Gotzsche PC. Overdiagnosis in organised mammography screening in Denmark. A comparative study. BMC Women’s Health. 2009;9:36. doi: 10.1186/1472-6874-9-36.PubMedCrossRefPubMedCentralGoogle Scholar
  8. 8.
    de Gelder R, Heijnsdijk EA, van Ravesteyn NT, Fracheboud J, Draisma G, de Koning HJ. Interpreting overdiagnosis estimates in population-based mammography screening. Epidemiol Rev. 2011;33(1):111–21. doi: 10.1093/epirev/mxr009.PubMedCrossRefPubMedCentralGoogle Scholar
  9. 9.
    Kalager M, Adami HO, Bretthauer M, Tamimi RM. Overdiagnosis of invasive breast cancer due to mammography screening: results from the Norwegian screening program. Ann Intern Med. 2012;156(7):491–9. doi: 10.7326/0003-4819-156-7-201204030-00005.PubMedCrossRefGoogle Scholar
  10. 10.
    Falk RS, Hofvind S, Skaane P, Haldorsen T. Overdiagnosis among women attending a population-based mammography screening program. Int J Cancer. 2013;133(3):705–12. doi: 10.1002/ijc.28052.PubMedCrossRefPubMedCentralGoogle Scholar
  11. 11.
    Welch HG, Passow HJ. Quantifying the benefits and harms of screening mammography. JAMA Intern Med. 2014;174(3):448–54. doi: 10.1001/jamainternmed.2013.13635.PubMedCrossRefGoogle Scholar
  12. 12.
    Independent UK Panel on Breast Cancer Screening. The benefits and harms of breast cancer screening: an independent review. Lancet. 2012;380(9855):1778–86. doi: 10.1016/S0140-6736(12)61611-0.CrossRefGoogle Scholar
  13. 13.
    Marmot MG, Altman DG, Cameron DA, Dewar JA, Thompson SG, Wilcox M. The benefits and harms of breast cancer screening: an independent review. Br J Cancer. 2013;108(11):2205–40. doi: 10.1038/bjc.2013.177.PubMedCrossRefPubMedCentralGoogle Scholar
  14. 14.
    International Agency for Research on Cancer (IARC). IARC handbooks of cancer prevention—breast cancer screening. Geneva: World Health Organisation; 2002.Google Scholar
  15. 15.
    Welch HG, Black WC. Overdiagnosis in cancer. J Natl Cancer Inst. 2010;102(9):605–13. doi: 10.1093/jnci/djq099.PubMedCrossRefGoogle Scholar
  16. 16.
    Grobin W. Diabetes in the aged: underdiagnosis and overtreatment. Can Med Assoc J. 1970;103(9):915–23.PubMedPubMedCentralGoogle Scholar
  17. 17.
    Feinstein AR, Esdaile JM. Incidence, prevalence, and evidence. Scientific problems in epidemiologic statistics for the occurrence of cancer. Am J Med. 1987;82(1):113–23.PubMedCrossRefGoogle Scholar
  18. 18.
    Morrison A. Screening in chronic disease. New York: Oxford University Press; 1985.Google Scholar
  19. 19.
    Black WC. Overdiagnosis: an underrecognized cause of confusion and harm in cancer screening. J Natl Cancer Inst. 2000;92(16):1280–2.PubMedCrossRefGoogle Scholar
  20. 20.
    Etzioni R, Penson DF, Legler JM, et al. Overdiagnosis due to prostate-specific antigen screening: lessons from US prostate cancer incidence trends. J Natl Cancer Inst. 2002;94(13):981–90.PubMedCrossRefGoogle Scholar
  21. 21.
    Hofmann B. The technological invention of disease—on disease, technology and values. Oslo: Universitetet i Oslo; 2002.Google Scholar
  22. 22.
    King L. What is a disease? Philos Sci. 1954;21:193–203.CrossRefGoogle Scholar
  23. 23.
    Reznek L. The nature of disease. New York: Routledge & Keagen Paul; 1987.Google Scholar

Copyright information

© Springer Science+Business Media Dordrecht 2014

Authors and Affiliations

  1. 1.University College of GjøvikGjøvikNorway
  2. 2.Faculty of Medicine, Centre for Medical EthicsUniversity of OsloOsloNorway

Personalised recommendations