Quantification of overdiagnosis in randomised trials of cancer screening: an overview and re-analysis of systematic reviews

Theis Voss; Mikela Krag; Frederik Martiny; Bruno Heleno; Karsten Juhl Jørgensen; John Brandt Brodersen

doi:10.1016/j.canep.2023.102352

Quantification of overdiagnosis in randomised trials of cancer screening: an overview and re-analysis of systematic reviews

Cancer Epidemiol. 2023 Jun:84:102352. doi: 10.1016/j.canep.2023.102352. Epub 2023 Mar 22.

Authors

Theis Voss¹, Mikela Krag², Frederik Martiny³, Bruno Heleno⁴, Karsten Juhl Jørgensen⁵, John Brandt Brodersen⁶

Affiliations

¹ The Centre of General Practice in Copenhagen, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Post box 2099, DK-1014 Copenhagen K, Denmark. Electronic address: t.voss@sund.ku.dk.
² The Centre of General Practice in Copenhagen, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Post box 2099, DK-1014 Copenhagen K, Denmark.
³ The Centre of General Practice in Copenhagen, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Post box 2099, DK-1014 Copenhagen K, Denmark; Center for Social Medicine, Bispebjerg and Frederiksberg Hospital, Copenhagen, Denmark.
⁴ CHRC, NOVA Medical School, Faculdade de Ciências Médicas, NMS, FCM , Universidade Nova de Lisboa, Lisbon, Portugal.
⁵ Centre for Evidence-Based Medicine Odense (CEBMO) and Cochrane Denmark, Department of Clinical Research, University of Southern Denmark, JB Winsløwsvej 9b, 3rd Floor, 5000 Odense, Denmark; Open Patient data Exploratory Network (OPEN), Odense University Hospital, Odense, Denmark.
⁶ The Centre of General Practice in Copenhagen, Department of Public Health, University of Copenhagen, Øster Farimagsgade 5, Post box 2099, DK-1014 Copenhagen K, Denmark; The Research Unit for General Practice in Region Zealand, Øster Farimagsgade 5, Post box 2099, DK-1014 Copenhagen K, Denmark; Research Unit for General Practice, Department of Community Medicine, Faculty of Health Sciences, UiT The Arctic University of Norway, Tromsø.

PMID: 36963292
DOI: 10.1016/j.canep.2023.102352

Abstract

The degree of overdiagnosis in common cancer screening trials is uncertain due to inadequate design of trials, varying definition and methods used to estimate overdiagnosis. Therefore, we aimed to quantify the risk of overdiagnosis for the most widely implemented cancer screening programmes and assess the implications of design limitations and biases in cancer screening trials on the estimates of overdiagnosis by conducting an overview and re-analysis of systematic reviews of cancer screening. We searched PubMed and the Cochrane Library from their inception dates to November 29, 2021. Eligible studies included systematic reviews of randomised trials comparing cancer screening interventions to no screening, which reported cancer incidence for both trial arms. We extracted data on study characteristics, cancer incidence and assessed the risk of bias using the Cochrane Collaboration's risk of bias tool. We included 19 trials described in 30 articles for review, reporting results for the following types of screening: mammography for breast cancer, chest X-ray or low-dose CT for lung cancer, alpha-foetoprotein and ultrasound for liver cancer, digital rectal examination, prostate-specific antigen, and transrectal ultrasound for prostate cancer, and CA-125 test and/or ultrasound for ovarian cancer. No trials on screening for melanoma were eligible. Only one trial (5%) had low risk in all bias domains, leading to a post-hoc meta-analysis, excluding trials with high risk of bias in critical domains, finding the extent of overdiagnosis ranged from 17% to 38% across cancer screening programmes. We conclude that there is a significant risk of overdiagnosis in the included randomised trials on cancer screening. We found that trials were generally not designed to estimate overdiagnosis and many trials had high risk of biases that may draw the estimates of overdiagnosis towards the null. In effect, the true extent of overdiagnosis due to cancer screening is likely underestimated.

Keywords: Cancer; Overdiagnosis; Screening.

Publication types

Meta-Analysis
Review

MeSH terms

Breast Neoplasms* / diagnosis
Breast Neoplasms* / epidemiology
Early Detection of Cancer
Humans
Male
Overdiagnosis
Prostatic Neoplasms* / diagnosis
Prostatic Neoplasms* / epidemiology
Randomized Controlled Trials as Topic
Systematic Reviews as Topic