Format

Send to

Choose Destination
Br J Cancer. 2009 Jun 2;100(11):1806-11. doi: 10.1038/sj.bjc.6605062. Epub 2009 Apr 28.

Prevalent cases in observational studies of cancer survival: do they bias hazard ratio estimates?

Author information

1
Department of Oncology, Strangeways Research Laboratory, University of Cambridge, Worts Causeway, Cambridge CB1 8RN, UK. azzatoe2@mail.nih.gov

Abstract

Observational epidemiological studies often include prevalent cases recruited at various times past diagnosis. This left truncation can be dealt with in non-parametric (Kaplan-Meier) and semi-parametric (Cox) time-to-event analyses, theoretically generating an unbiased hazard ratio (HR) when the proportional hazards (PH) assumption holds. However, concern remains that inclusion of prevalent cases in survival analysis results inevitably in HR bias. We used data on three well-established breast cancer prognosticators - clinical stage, histopathological grade and oestrogen receptor (ER) status - from the SEARCH study, a population-based study including 4470 invasive breast cancer cases (incident and prevalent), to evaluate empirically the effectiveness of allowing for left truncation in limiting HR bias. We found that HRs of prognostic factors changed over time and used extended Cox models incorporating time-dependent covariates. When comparing Cox models restricted to subjects ascertained within six months of diagnosis (incident cases) to models based on the full data set allowing for left truncation, we found no difference in parameter estimates (P=0.90, 0.32 and 0.95, for stage, grade and ER status respectively). Our results show that use of prevalent cases in an observational epidemiological study of breast cancer does not bias the HR in a left truncation Cox survival analysis, provided the PH assumption holds true.

PMID:
19401693
PMCID:
PMC2695697
DOI:
10.1038/sj.bjc.6605062
[Indexed for MEDLINE]
Free PMC Article

Supplemental Content

Full text links

Icon for Nature Publishing Group Icon for PubMed Central
Loading ...
Support Center