{"entity":{"id":"b-overdiagnosis","kind":"bottleneck","name":"Overdiagnosis and false alarms","aka":[],"tldr":"Finding more cancer is not the same as saving lives. Screening also finds cancers that would never have hurt anyone, and treats them.","summary":"Overdiagnosis is the detection of a cancer that would never have caused symptoms or death in the person's lifetime. It is intrinsic to screening for indolent lesions and is largest where the reservoir of subclinical disease is big: thyroid, prostate, ductal carcinoma in situ of the breast, some small lung nodules and low-grade renal masses. South Korea's ultrasound-driven fifteen-fold rise in thyroid cancer incidence with unchanged mortality is the textbook case. Every overdiagnosed cancer is treated, with surgery, radiotherapy or lifelong hormone replacement, and every false positive generates anxiety, biopsies and cost. New multi-cancer and AI-based detection tests inherit the same problem unless they are evaluated on mortality and paired with active surveillance and risk-adapted management pathways. Reversing overdiagnosis requires changing the definition of what is called cancer, and changing what happens after a positive test.","asOf":"2026-09-08","links":[{"label":"Welch & Black, Overdiagnosis in cancer (JNCI 2010)","url":"https://doi.org/10.1093/jnci/djq099"},{"label":"Ahn, Kim & Welch, Korea's thyroid-cancer epidemic (NEJM 2014)","url":"https://doi.org/10.1056/NEJMp1409841"},{"label":"Independent UK Panel on Breast Cancer Screening (Lancet 2012)","url":"https://doi.org/10.1016/S0140-6736(12)61611-0"}],"tags":[],"related":["idea-thyroid-overdiagnosis-reversal","idea-prev-thyroid-no-screening-no-small-biopsy","idea-prev-ptmc-active-surveillance-default","idea-prev-low-risk-dcis-surveillance-pathway","idea-prev-indolent-lesion-nomenclature-body","idea-prev-gleason6-terminology-rct","idea-prev-prostate-as-triggered-biopsy","idea-prev-small-renal-mass-surveillance","idea-prev-lung-nodule-ai-discharge","idea-prev-blood-precursor-watch-registry","idea-prev-annual-overdiagnosis-reporting","idea-prev-screening-stop-by-life-expectancy","idea-prev-barrett-surveillance-deescalation","idea-prev-melanoma-ai-thick-melanoma-metric","idea-prev-incidentaloma-natural-history-cohort","idea-prev-ipmn-surveillance-stop-rule","idea-prev-pathology-ai-borderline-anchor","idea-prev-frail-elderly-primary-endocrine-breast","idea-prev-omit-radiotherapy-low-risk-breast-default","idea-prev-modern-autopsy-reservoir-studies","idea-moon-indolence-classifiers-with-screening"],"cancers":["thyroid","prostate","breast-hr-positive","nsclc","rcc"],"sections":[],"technologies":["active-surveillance","active-surveillance-thyroid","mp-mri","mammography","low-dose-ct-screening","partial-nephrectomy-active-surveillance","mced","thyroid-fna-molecular"],"targets":[],"drugs":[],"companies":[],"institutions":[],"pathways":[],"terms":["low-risk-dtc","psa","gleason-grade-group","ppv","bethesda-category"],"trials":["protect","precision-mri","nlst-nelson"],"people":[],"bottlenecks":[],"keyPapers":["paper-welch-j-natl-cancer-inst","paper-independent-uk-panel-on-breast-cancer-lancet","paper-ahn-n-engl-j-med"],"journals":[],"dependsOn":[],"notes":[],"stage":"prevention-detection","severity":"major","metrics":[{"label":"Increase in thyroid cancer incidence in South Korea 1993-2011 with no change in mortality","value":"15-fold","source":"Ahn, Kim & Welch, NEJM 2014","url":"https://doi.org/10.1056/NEJMp1409841"},{"label":"Estimated breast cancers overdiagnosed for each breast cancer death prevented by UK mammography screening","value":"About 3 overdiagnosed per death prevented","source":"Independent UK Panel on Breast Cancer Screening, Lancet 2012","url":"https://doi.org/10.1016/S0140-6736(12)61611-0"},{"label":"Prostate cancer-specific mortality at 15 years with active monitoring vs surgery vs radiotherapy in PSA-detected disease (ProtecT)","value":"3.1% vs 2.2% vs 2.9% (no significant difference)","source":"Hamdy et al., NEJM 2023","url":"https://doi.org/10.1056/NEJMoa2214122"}],"causes":["Many organs harbour a large reservoir of indolent lesions that meet histological criteria for cancer but never progress.","Higher-resolution imaging and lower biopsy thresholds detect ever-smaller lesions.","Pathology cannot yet reliably distinguish indolent from aggressive lesions at diagnosis.","Clinicians and patients find it hard to leave a diagnosed cancer untreated, even when surveillance is safe.","Screening programmes are judged on cancers found rather than deaths prevented."],"currentEfforts":["ProtecT and PRECISION established active monitoring and MRI-first diagnosis as safe standards for low-risk prostate cancer, and active surveillance is guideline-endorsed for papillary thyroid microcarcinoma.","The COMET trial randomised low-risk DCIS to active monitoring vs surgery and reported non-inferior two-year invasive cancer rates.","Lung-RADS and PI-RADS structured reporting reduce unnecessary biopsies after CT and MRI.","South Korea and the US Preventive Services Task Force recommend against screening asymptomatic adults for thyroid cancer.","The Preventing Overdiagnosis conference series and BMJ Too Much Medicine campaign maintain a research and policy agenda.","Proposals to rename low-risk lesions (for example, IDLE tumours) aim to remove the word cancer from indolent findings."],"successLooksLike":"Every screening programme reports overdiagnosis and false-positive rates alongside deaths prevented, active surveillance is the default for defined low-risk lesions in thyroid, prostate and DCIS, and thyroid cancer incidence falls back toward its mortality-justified baseline."},"route":"/bottlenecks/b-overdiagnosis/","neighbours":{"idea":[{"id":"idea-prev-mced-positive-resolution-pathway","kind":"idea","name":"A 28-day national pathway for people with a positive multi-cancer blood test","route":"/ideas/idea-prev-mced-positive-resolution-pathway/"},{"id":"idea-prev-mced-pretest-decision-aid","kind":"idea","name":"A mandatory decision aid before any multi-cancer blood test","route":"/ideas/idea-prev-mced-pretest-decision-aid/"},{"id":"idea-prev-incidentaloma-natural-history-cohort","kind":"idea","name":"A ten-year cohort of incidental findings to calibrate follow-up 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default for tiny papillary thyroid cancers","route":"/ideas/idea-prev-ptmc-active-surveillance-default/"},{"id":"idea-prev-low-risk-dcis-surveillance-pathway","kind":"idea","name":"After the COMET trial: surveillance pathways and a new name for low-risk DCIS","route":"/ideas/idea-prev-low-risk-dcis-surveillance-pathway/"},{"id":"idea-prev-lung-nodule-ai-discharge","kind":"idea","name":"AI malignancy scores to end repeat scans and biopsies for benign lung nodules","route":"/ideas/idea-prev-lung-nodule-ai-discharge/"},{"id":"idea-prev-pathology-ai-borderline-anchor","kind":"idea","name":"AI second reads to stop borderline lesions being upgraded to cancer","route":"/ideas/idea-prev-pathology-ai-borderline-anchor/"},{"id":"idea-prev-indolent-lesion-nomenclature-body","kind":"idea","name":"An international body to rename indolent lesions so 'cancer' means 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carry","route":"/ideas/idea-prev-modern-autopsy-reservoir-studies/"},{"id":"idea-moon-indolence-classifiers-with-screening","kind":"idea","name":"Molecular indolence classifiers bundled with every screening programme","route":"/ideas/idea-moon-indolence-classifiers-with-screening/"},{"id":"idea-prev-mri-first-prostate-screening-prs","kind":"idea","name":"MRI-first prostate screening with genetic pre-selection","route":"/ideas/idea-prev-mri-first-prostate-screening-prs/"},{"id":"idea-fund-omission-deescalation-trials","kind":"idea","name":"Payer-funded trials that omit surgery or radiotherapy in low-risk patients","route":"/ideas/idea-fund-omission-deescalation-trials/"},{"id":"idea-prev-fit-risk-adapted-thresholds","kind":"idea","name":"Personalised stool-test cut-offs by age, sex and prior results","route":"/ideas/idea-prev-fit-risk-adapted-thresholds/"},{"id":"idea-prev-prostate-as-triggered-biopsy","kind":"idea","name":"Prostate active surveillance without scheduled biopsies: MRI and blood tests decide","route":"/ideas/idea-prev-prostate-as-triggered-biopsy/"},{"id":"idea-prostate-per-lesion-mri-audit-before-focal-treatment","kind":"idea","name":"Publish a per-lesion miss rate for every prostate MRI service before it is allowed to guide focal treatment","route":"/ideas/idea-prostate-per-lesion-mri-audit-before-focal-treatment/"},{"id":"idea-data-ai-screening-endpoints","kind":"idea","name":"Require stage-shift or interval-cancer endpoints for AI in cancer screening","route":"/ideas/idea-data-ai-screening-endpoints/"},{"id":"idea-gbc-risk-targeted-ultrasound-in-high-incidence-regions","kind":"idea","name":"Risk-targeted ultrasound screening in high-incidence regions, tested against usual care","route":"/ideas/idea-gbc-risk-targeted-ultrasound-in-high-incidence-regions/"},{"id":"idea-prev-ai-mammogram-risk-intervals","kind":"idea","name":"Set each woman's mammogram interval from her last mammogram, using AI 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men choose","route":"/ideas/idea-prev-gleason6-terminology-rct/"},{"id":"idea-thyroid-overdiagnosis-reversal","kind":"idea","name":"Ultrasound restraint and surveillance to reverse thyroid cancer overdiagnosis","route":"/ideas/idea-thyroid-overdiagnosis-reversal/"},{"id":"idea-prev-small-renal-mass-surveillance","kind":"idea","name":"Watch small kidney tumours rather than remove them, with a national registry","route":"/ideas/idea-prev-small-renal-mass-surveillance/"}],"cancer":[{"id":"ductal-carcinoma-in-situ","kind":"cancer","name":"Ductal carcinoma in situ (DCIS)","route":"/cancers/ductal-carcinoma-in-situ/"},{"id":"breast-hr-positive","kind":"cancer","name":"HR-positive / HER2-negative breast cancer","route":"/cancers/breast-hr-positive/"},{"id":"nsclc","kind":"cancer","name":"Non-small-cell lung cancer","route":"/cancers/nsclc/"},{"id":"pituitary-tumours","kind":"cancer","name":"Pituitary tumours (pituitary neuroendocrine tumours) and pituitary 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