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Death Does Matter — Cancer Risk in Patients With End-Stage Renal Disease

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ABSTRACT

Patients with end-stage renal disease (ESRD) have a high mortality rate. We hypothesized that not accounting for death as a competing risk overestimates the event rate caused by ESRD. Thus, we examined the cancer risk for patients with ESRD (ESRDPos) after death as a competing risk event had been adjusted for. Patients with newly diagnosed ESRD (n = 64,299) between 1999 and 2007, together with age- and sex-matched controls without ESRD (ESRDNeg) (n = 128,592) were enrolled (1:2). In a Cox proportional hazards model that included death as a competing risk, ESRDPos patients in Taiwan had a lower overall incidence (subdistribution hazard ratio [sdHR] = 1.29) of cancer than did ESRDNeg patients in a Cox model that did not include death as a competing risk (HR = 1.70). After competing mortality had been adjusted for, ESRDPos patients ≥70 (sdHR = 0.82) and ESRDPos patients on long-term dialysis (> 5 follow-up years, sdHR = 0.62), had a lower risk for developing cancer than did ESRDNeg patients. This finding supported our hypothesis that standard survival analyses overestimate the event rate, especially when the mortality rate is high. It also showed that ESRDPos patients, when they grow older, were far less likely to develop cancer and far more likely to die because of underlying illnesses that might also affect the risk of death because of ESRD.

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(A) Cumulative incidence of cancer estimated using the Kaplan–Meier method without accounting for competing risk events. (B) Cumulative incidence of cancer estimated using the Kaplan–Meier method and accounting for competing risk events.
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Figure 1: (A) Cumulative incidence of cancer estimated using the Kaplan–Meier method without accounting for competing risk events. (B) Cumulative incidence of cancer estimated using the Kaplan–Meier method and accounting for competing risk events.

Mentions: There were significant differences in the cumulative incidences of cancer in the log-rank tests with and without the competing mortality adjustment between the ESRDPos and ESRDNeg patients (Figure 1A and B; both P < 0.001). ESRDPos patients had a significantly higher risk of developing cancer than did ESRDNeg patients. The 1-, 5-, and 10-year cumulative incidences of cancer without the competing mortality adjustment were 0.94% versus 0.49%, 6.02% versus 3.62, and 12.28% versus 7.76%, respectively, in the ESRDPos patients compared with the ESRDNeg patients. In contrast, the 1-, 5-, and 10-year cumulative incidences of cancer with the competing mortality adjustment were 0.75% versus 0.57%, 4.76% versus 3.65%, and 9.23% versus 7.12%, respectively, in the ESRDPos patients compared with the ESRDNeg patients.


Death Does Matter — Cancer Risk in Patients With End-Stage Renal Disease
(A) Cumulative incidence of cancer estimated using the Kaplan–Meier method without accounting for competing risk events. (B) Cumulative incidence of cancer estimated using the Kaplan–Meier method and accounting for competing risk events.
© Copyright Policy - open-access
Related In: Results  -  Collection

License
Show All Figures
getmorefigures.php?uid=PMC4998265&req=5

Figure 1: (A) Cumulative incidence of cancer estimated using the Kaplan–Meier method without accounting for competing risk events. (B) Cumulative incidence of cancer estimated using the Kaplan–Meier method and accounting for competing risk events.
Mentions: There were significant differences in the cumulative incidences of cancer in the log-rank tests with and without the competing mortality adjustment between the ESRDPos and ESRDNeg patients (Figure 1A and B; both P < 0.001). ESRDPos patients had a significantly higher risk of developing cancer than did ESRDNeg patients. The 1-, 5-, and 10-year cumulative incidences of cancer without the competing mortality adjustment were 0.94% versus 0.49%, 6.02% versus 3.62, and 12.28% versus 7.76%, respectively, in the ESRDPos patients compared with the ESRDNeg patients. In contrast, the 1-, 5-, and 10-year cumulative incidences of cancer with the competing mortality adjustment were 0.75% versus 0.57%, 4.76% versus 3.65%, and 9.23% versus 7.12%, respectively, in the ESRDPos patients compared with the ESRDNeg patients.

View Article: PubMed Central - PubMed

ABSTRACT

Patients with end-stage renal disease (ESRD) have a high mortality rate. We hypothesized that not accounting for death as a competing risk overestimates the event rate caused by ESRD. Thus, we examined the cancer risk for patients with ESRD (ESRDPos) after death as a competing risk event had been adjusted for. Patients with newly diagnosed ESRD (n&#8202;=&#8202;64,299) between 1999 and 2007, together with age- and sex-matched controls without ESRD (ESRDNeg) (n&#8202;=&#8202;128,592) were enrolled (1:2). In a Cox proportional hazards model that included death as a competing risk, ESRDPos patients in Taiwan had a lower overall incidence (subdistribution hazard ratio [sdHR]&#8202;=&#8202;1.29) of cancer than did ESRDNeg patients in a Cox model that did not include death as a competing risk (HR&#8202;=&#8202;1.70). After competing mortality had been adjusted for, ESRDPos patients &ge;70 (sdHR&#8202;=&#8202;0.82) and ESRDPos patients on long-term dialysis (&gt; 5 follow-up years, sdHR&#8202;=&#8202;0.62), had a lower risk for developing cancer than did ESRDNeg patients. This finding supported our hypothesis that standard survival analyses overestimate the event rate, especially when the mortality rate is high. It also showed that ESRDPos patients, when they grow older, were far less likely to develop cancer and far more likely to die because of underlying illnesses that might also affect the risk of death because of ESRD.

No MeSH data available.


Related in: MedlinePlus