Competing risks in epidemiology: possibilities and pitfalls

Andersen, Per Kragh; Geskus, Ronald B; de Witte, Theo; Putter, Hein

doi:10.1093/ije/dyr213

Cited by 986Statistical Methods in EpidemiologyProbability and Statistical ResearchStatistical Methods and Inference

Competing risks in epidemiology: possibilities and pitfalls

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Andersen, Per Kragh, Geskus, Ronald B, de Witte, Theo, Putter, Hein·2012·International Journal of Epidemiology

DOI 10.1093/ije/dyr213PMC PMC3396320

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Abstract

BACKGROUND: In studies of all-cause mortality, the fundamental epidemiological concepts of rate and risk are connected through a well-defined one-to-one relation. An important consequence of this relation is that regression models such as the proportional hazards model that are defined through the hazard (the rate) immediately dictate how the covariates relate to the survival function (the risk). METHODS: This introductory paper reviews the concepts of rate and risk and their one-to-one relation in all-cause mortality studies and introduces the analogous concepts of rate and risk in the context of competing risks, the cause-specific hazard and the cause-specific cumulative incidence function. RESULTS: The key feature of competing risks is that the one-to-one correspondence between cause-specific hazard and cumulative incidence, between rate and risk, is lost. This fact has two important implications. First, the naïve Kaplan-Meier that takes the competing events as censored observations, is biased. Secondly, the way in which covariates are associated with the cause-specific hazards may not coincide with the way these covariates are associated with the cumulative incidence. An example with relapse and non-relapse mortality as competing risks in a stem cell transplantation study is used for illustration. CONCLUSION: The two implications of the loss of one-to-one correspondence between cause-specific hazard and cumulative incidence should be kept in mind when deciding on how to make inference in a competing risks situation.

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The design of our study (an incidence surveillance system), the possible presence of competitive causes of death and the limited period of observation prevent statistical inferences on the association between exposure and time to event (age or latency).
“The design of our study (an incidence surveillance system), the possible presence of competitive causes of death and the limited period of observation prevent statistical inferences on the association between exposure and time to event (age or latency).39 40”
From Malignant mesothelioma due to non-occupational asbestos exposure from the Italian national surveillance system (ReNaM): epidemiology and public health issues (2015) · cites this paper as [40]
The Competing risks section explains why deaths from other causes complicate a naïve analysis. But it also says inference can be made in the presence of competing risks; the 'Independent' competing risks section likewise says independence is not needed for inference. The paper does not assess the citing study’s surveillance design or observation period, so it does not support the conclusion that those factors prevent statistical inference in that study. (LLM, conf=0.84)
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Authors: Andersen, P. K., Geskus, R. B., de Witte, T., & Putter, H.
Affiliations: University of Copenhagen (DK)
Amsterdam UMC Location University of Amsterdam (NL)
Leiden University Medical Center (NL)
Corresponding author: Putter, Hein
ORCID: Andersen, Per Kragh
Geskus, Ronald B
Putter, Hein
Venue: International Journal of Epidemiology
Publisher: Oxford University Press (OUP)
Published: 2012-01-09
Volume: 41
Issue: 3
Pages: 861-870
ISSN: 0300-5771 (ISSN-L)
1464-3685
DOI: 10.1093/ije/dyr213
PMC: PMC3396320
OpenAlex: W2154117702
Semantic Scholar: fad89d6c4d4b7b80df8a26be5a2c8e1dd54eec29
Cited by: 985
References: 18
Citations by year: 2026: 83 · 2025: 59 · 2024: 78 · 2023: 75 · 2022: 71 · 2021: 66 · 2020: 102 · 2019: 88 · 2018: 77 · 2017: 77 · 2016: 73 · 2015: 47 · 2014: 51 · 2013: 29 · 2012: 9
FWCI: 41.50
Type: journal article
Language: en
Open access: bronze
doi.org
Locations: International Journal of Epidemiology (publishedVersion)
Europe PMC (PubMed Central) (publishedVersion)
PubMed Central (publishedVersion)
PubMed (publishedVersion)
Data Archiving and Networked Services (DANS) (submittedVersion)
Leiden Repository (Leiden University) (submittedVersion)
HighWire Press Open Archive (submittedVersion)
Pure Amsterdam UMC (submittedVersion)
Research at the University of Copenhagen (University of Copenhagen) (submittedVersion)
Radboud Repository (Radboud University) (submittedVersion)
Funders: U.S. Public Health Service (R01-54706-12)
Topics: Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods in Epidemiology
Physical Sciences › Mathematics › Statistics and Probability › Probability and Statistical Research
Physical Sciences › Mathematics › Statistics and Probability › Statistical Methods and Inference
Keywords: competing risks, all-cause mortality, cause-specific hazard, cumulative incidence function, stem cell transplantation
MeSH terms: Humans, Models, Theoretical, Mortality, Survival Analysis, Epidemiologic Studies, Risk Assessment

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