# Lead time and overdiagnosis in prostate-specific antigen screening: importance of methods and context

Source: https://onco.cc/key-papers/paper-draisma-lead-time-overdiagnosis-psa-jnci-2009/  
OnCo record `paper-draisma-lead-time-overdiagnosis-psa-jnci-2009` (Key paper). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

Estimates of how many screen-detected prostate cancers would never have caused trouble ranged from a quarter to more than four fifths. Three independent models were run side by side to find out why, and showed the answer depends almost entirely on how the question is asked.

## Summary

Gerrit Draisma, Ruth Etzioni and colleagues ran three independently developed models of prostate cancer progression and detection, all calibrated to Surveillance, Epidemiology, and End Results incidence, to estimate lead time and overdiagnosis among United States men aged 54 to 80 between 1985 and 2000. They also compared the United States estimates against earlier ones from the Rotterdam section of the European screening trial.

The finding is a methodological one with a very practical consequence. The three models agreed closely with each other for any given definition of lead time, and disagreed substantially across definitions: mean lead time ranged from 5.4 to 6.9 years and overdiagnosis from 23 to 42 percent of screen-detected cancers in the United States calibration, while the Rotterdam calibration of the same model family gave 7.9 years and 66 percent. Quoting a single overdiagnosis percentage for prostate screening without saying which definition and which population it came from is therefore not meaningful.

## Fields

- Kind: Key paper
- Last checked: 2026-09-25
- Also known as: Draisma 2009; MISCAN prostate overdiagnosis; Etzioni lead time prostate
- Tags: prostate-evidence
- Journal: JNCI: Journal of the National Cancer Institute
- Year: 2009
- DOI: 10.1093/jnci/djp001
- Authors: Draisma G, Etzioni R, Tsodikov A, et al.
- Findings: Among screen-detected cancers that would have been diagnosed in the patients' lifetimes, estimated mean lead time ranged from 5.4 to 6.9 years across the three models.; Overdiagnosis ranged from 23 to 42 percent of all screen-detected cancers in the models calibrated to United States data.; The original MISCAN model fitted to ERSPC Rotterdam data predicted a mean lead time of 7.9 years and overdiagnosis of 66 percent; recalibrated to United States data the same model gave 6.9 years and 42 percent.; Published estimates before this work ranged from 3 to 12 years for lead time and from 25 percent to more than 80 percent for overdiagnosis.; The three models yielded similar estimates for any single definition of lead time but estimates differed across definitions.
- What it means: The reference for anyone quoting an overdiagnosis figure in prostate cancer. The honest statement is a range with its definition and its population attached, and this paper is the reason no single overdiagnosis figure is quoted for prostate cancer.
- Caveats: Model-based estimates calibrated to registry incidence, not direct observation of individual men.; Calibrated to a period of intense and largely unstructured United States testing between 1985 and 2000; the modern pathway with magnetic resonance imaging triage produces a different answer.; Overdiagnosis of a cancer is only harmful if it leads to treatment, and the models do not measure treatment decisions.

## Sources

- J Natl Cancer Inst 2009: https://doi.org/10.1093/jnci/djp001
- PubMed: https://pubmed.ncbi.nlm.nih.gov/19276453/

## Connected records

- key papers: [A 16-yr Follow-up of the European Randomized study of Screening for Prostate Cancer](https://onco.cc/key-papers/paper-hugosson-eur-urol/), [ERSPC: screening and prostate cancer mortality in a randomised European study](https://onco.cc/key-papers/paper-schroder-erspc-screening-mortality-nejm-2009/), [Overdiagnosis and overtreatment of prostate cancer](https://onco.cc/key-papers/paper-loeb-overdiagnosis-overtreatment-prostate-eur-urol-2014/), [Prostate cancer diagnosis and treatment after the introduction of prostate-specific antigen screening, 1986 to 2005](https://onco.cc/key-papers/paper-welch-albertsen-psa-era-diagnosis-treatment-jnci-2009/)
- roadmaps: [Prostate cancer roadmap: from Huggins and the discovery that a cancer can depend on a hormone, through the PSA epidemic and what it cost, the androgen receptor drugs, the DNA repair subset and PSMA, to a 2032 registry watch](https://onco.cc/roadmaps/prostate-roadmap/)
- cancers: [Localised prostate cancer, very low and low risk](https://onco.cc/cancers/prostate-low-risk/), [Prostate cancer](https://onco.cc/cancers/prostate/)
- fronts: [Early Detection & Screening](https://onco.cc/fronts/early-detection/)
- terms: [Lead time, and lead-time bias](https://onco.cc/terms/lead-time-bias/), [Number needed to screen (and number needed to diagnose)](https://onco.cc/terms/number-needed-to-screen/), [Overdiagnosis](https://onco.cc/terms/overdiagnosis/), [Overtreatment](https://onco.cc/terms/overtreatment/), [PSA (prostate-specific antigen)](https://onco.cc/terms/psa/), [Screening](https://onco.cc/terms/screening/)
- bottlenecks: [Biomarkers are not validated or standardised](https://onco.cc/bottlenecks/b-biomarker-validation/), [Overdiagnosis and false alarms](https://onco.cc/bottlenecks/b-overdiagnosis/), [The hardest cancers are found late](https://onco.cc/bottlenecks/b-early-detection/)
- journals: [JNCI: Journal of the National Cancer Institute](https://onco.cc/journals/jnci/)
- ideas: [Judge a prostate screening programme on metastatic presentation, not on incidence or mortality](https://onco.cc/ideas/idea-prostate-metastatic-presentation-as-the-screening-endpoint/)

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