Influence of follow-up, screening age, interval, and compliance on overdiagnosis of ductal carcinoma in situ (DCIS): a modelling study

Overdiagnosis estimates of ductal carcinoma in situ (DCIS) vary from 20-91%, which complicates screening communication and optimization. The aim was to quantify the influence of follow-up time and screening setting on overdiagnosis of DCIS. The fully validated micro-simulation Markov model for DCIS (SimDCIS) was used to estimate DCIS overdiagnosis in different screening settings with varying follow-up. DCIS overdiagnosis was defined as the number of diagnosed DCIS (screen-, clinically-detected, or progressed to invasive breast cancer) in screening that would not have been diagnosed without screening. Outcomes were presented as overdiagnosed proportion and rate. The base cohort was screened biennially from age 50-74 with 76% compliance and 25 years (y) follow-up and compared to the non-screened cohort. Follow-up was varied from 2-25y, screening start 40-74y, screening interval 1-5y and compliance 50-100%. DCIS overdiagnosis was estimated at 20% of all diagnosed DCIS and 38.1 overdiagnosed DCIS per 100,000 women screened biennially from age 50-74 at 76% compliance and 25y follow-up. The proportion of overdiagnosed DCIS increased with shorter follow-up (27% at 2y to 20% at 25y), older screening start age (1% at 40y to 15% at 74y), decreased screening interval (23% at 1y to 12% at 5y), and increased compliance (16% at half to 20% at full participation). In conclusion, reliable DCIS overdiagnosis estimates require attention to screening setting and ≥20 years follow-up. Older women (74y) showed up to seven times more overdiagnosis at initial screening than younger women (50y). Improved estimates can provide guidance in screening communication and optimization.