Overdiagnosis and underdiagnosis in BreastScreen Norway

A PhD project will investigate aspects of overdiagnosis and underdiagnosis in BreastScreen Norway. The goal of the project is to add to what is known about the potential harms of mammographic screening.
Last updated: 6/2/2021


Breast cancer is the most common type of cancer among women in Norway. About 3,500 new cases are diagnosed each year. Screening with mammography can detect breast cancer in an early stage. In Norway, women aged 50-69 are invited to BreastScreen Norway.

The principle behind mammography screening is to examine many otherwise healthy women to identify the few who have breast cancer. The goal of screening is to reduce breast cancer deaths and to offer women less aggressive treatment; however, screening also carries some risks. It is important to minimize the risks associated with screening, and avoid unnecessary treatment. 

BreastScreen Norway works continuously to minimize the risks of mammographic screening, including the risk of overdiagnosis or underdiagnosis of breast cancer, among others.

Overdiagnosies occurs when screening detects small, slow-growing tumours that would never have caused symptoms or been detected if a woman hadn´t been screened. It is currently not possible to determine which specific tumours are overdiagnosed and all women are offered treatment for their disease. Overdiagnosed women may undergo treatment that offers them little to no medical benefit. It is difficult to know how often overdiagnosis occurs because there is no agreement on how to best estimate it. Some studies have estimated that mammographic screening leads to a very low rate of overdiagnosis. Others have estimated relatively high rates of overdiagnosis.

Underdiagnosis can occur when a breast tumour is overlooked. These tumours can later be detected between two screening examinations because of symptoms. Tumours detected between two screening examinations often have a worse prognosis than breast cancers that are detected as a result of screening. Only a small percentage of breast cancer cases in a screening program are underdiagnosed. This means that many mammography images are needed to perform a robust study on this topic. Obtaining these data is challenging.

Awareness and knowledge about breast cancer, particularly overdiagnosis and underdiagnosis, can be important for women when they decide whether to participate in BreastScreen Norway.


The objective of this PhD project is to investigate overdiagnosis and underdiagnosis in BreastScreen Norway. The project consists of three papers based on separate studies that explore concepts related to overdiagnosis, underdiagnosis, and women’s knowledge about breast cancer in general and overdiagnosis in particular.


Study 1: Evaluate whether measurement error was present among tumour diameter data registered at the Cancer Registry of Norway and whether this had the potential to lead to under- or overstaging.

Published: Tsuruda KM, Hofvind S, Akslen LA, Hoff SR, Veierød MB. Terminal digit preference: a source of measurement error in breast cancer diameter reporting. Acta Oncol. 2020;59(3):260-7.

Study 2:  Determine whether tumour characteristics and survival are differentially associated with certain groups of cancers, and explore whether this could indicate if certain cancers are more likely to be over- or underdiagnosed on a group level.

Published: Tsuruda KM, Hovda T, Bhargava S, Veierød MB, Hofvind S. Survival among women diagnosed with screen-detected or interval breast cancer classified as true, minimal signs, or missed through an informed radiological review. Eur Radiol. 2021;31:2677–2686.

Study 3: Describe Norwegian women’s conceptual knowledge about mammographic screening in general, and overdiagnosis in particular. This was a cross-sectional study based on an online questionnaire sent to women aged 50-69 in Norway.

In progress.

Research team

The PhD candidate is Kaitlyn Tsuruda, MSc, Cancer Registry of Norway.

The primary investigator and supervisor of this project is Solveig Hofvind, head of the mammography section at the Cancer Registry of Norway, and professor of radiography at Oslo Metropolitan University.

Marit Veierød, professor in biostatistics at the University of Oslo, is the co-supervisor.

External collaborators include:

  • Lars A Akslen, Centre for Cancer Biomarkers CCBIO, University of Bergen and Haukeland University Hospital
  • Sameer Bhargava, Vestre Viken Hospital Trust
  • Gunvor G. Wåde, Oslo Metropolitan University
  • Nehmat Houssami, University of Sydney (Australia)
  • Tone Hovda, Vestre Viken Hospital Trust
  • Solveig Roth Hoff, Ålesund Hospital