Obligate Overdiagnosis Due to Mammographic Screening: A Direct Estimate for U.S. Women

Purpose To determine obligate overdiagnosis rates, defined as the percentage of women diagnosed with screen-detected breast cancer who die of causes other than breast cancer prior to clinical presentation of that cancer, for ductal carcinoma in situ (DCIS), invasive breast cancer, and all breast cancers. Materials and Methods Age-specific all-cause mortality rates from the Human Mortality Database, age-specific breast cancer incidence and mortality rates from Surveillance, Epidemiology, and End Results data, and estimates of mean lead times and lead time distributions from breast cancer screening trials are used to estimate obligate (or type 1) overdiagnosis rates for DCIS, invasive breast cancer, and all breast cancers (DCIS plus invasive) for U.S. women undergoing screening mammography. Mortality rates by age are used to estimate the number of women who die of causes other than breast cancer during the lead time afforded by screening mammography. Resulting age-dependent overdiagnosis rates, along with screen-detected breast cancer incidence by age, are used to estimate type 1 overdiagnosis rates for the U.S. screening population. Results Obligate overdiagnosis rates depend strongly on the age at which a woman is screened, ranging from less than 1% at age 40 years to 30%, 21%, and 22.5% at age 80 years for DCIS, invasive breast cancer, and all breast cancers, respectively. Type 1 overdiagnosis rates among screened women in the United States are estimated to be 9% for DCIS and approximately 7% for both invasive breast cancer and all breast cancers. Screening of women ages 40-49 years (or premenopausal women, as determined from patient history, starting at age 40 years) adds little to obligate overdiagnosis rates (0.15% for DCIS and less than 0.1% for invasive breast cancer and all breast cancers). Conclusion Type 1 overdiagnosis rates increase rapidly with age at screening. Obligate overdiagnosis occurs in 9% of DCIS and approximately 7% of both invasive breast cancer and all breast cancers in the U.S. mammographic screening population, with screening of women ages 40-49 years (or premenopausal women starting at age 40 years) making a negligible contribution of 0.15% to obligate overdiagnosis of DCIS and a contribution of less than 0.1% to the obligate overdiagnosis rates of invasive breast cancer and all breast cancers. ^© RSNA, 2017 Online supplemental material is available for this article.