Overestimating Overdiagnosis in Breast Cancer Screening

Overdiagnosis in breast cancer has been a focus of increasing concern with wide ranges of calculations made indirectly through the study of prospective randomized trials and analyses of large registries. While most admit that some degree of overdiagnosis is inherent with ductal carcinoma in situ (DCIS), the rate of overdiagnosis with invasive disease is highly controversial. Although it is generally accepted that overdiagnosis is calculated through indirect means and deductive reasoning, this is not entirely the case. Patients who refuse treatment, yet curiously return for follow-up, allow a direct glimpse at the natural history of screen-detected cancers. And historic autopsy studies offer information as to undiagnosed disease prevalence from the pre-screening era. While these autopsy studies support a modest degree of overdiagnosis in DCIS, they do not support widespread overdiagnosis for invasive cancer. The 1.3% mean incidence of invasive disease from seven autopsy studies correlates closely with disease prevalence, a direct observation that cancers do not remain quiescent in the breast until death. If invasive breast cancer does not regress in untreated patients and does not remain quiescent, then the high estimates being calculated for overdiagnosis are more likely to be length bias from long natural histories rather than true overdiagnosis.