title: Assessing Markov and time homogeneity assumptions in multi-state models: application in patients with gastric cancer undergoing surgery in the Iran cancer institute.
abstract: BACKGROUND
  Multi-state models are appropriate for cancer studies such as gastrectomy which have high mortality statistics. These models can be used to better describe the natural disease process. But reaching that goal requires making assumptions like Markov and homogeneity with time. The present study aims to investigate these hypotheses.
  
  
  METHODS
  Data from 330 patients with gastric cancer undergoing surgery at Iran Cancer Institute from 1995 to 1999 were analyzed. To assess Markov assumption and time homogeneity in modeling transition rates among states of multi-state model, Cox-Snell residuals, Akaikie information criteria and Schoenfeld residuals were used, respectively.
  
  
  RESULTS
  The assessment of Markov assumption based on Cox-Snell residuals and Akaikie information criterion showed that Markov assumption was not held just for transition rate of relapse (state 1-state 2) and for other transition rates - death hazard without relapse (state 1-state 3) and death hazard with relapse (state 2-state 3) - this assumption could also be made. Moreover, the assessment of time homogeneity assumption based on Schoenfeld residuals revealed that this assumption - regarding the general test and each of the variables in the model - was held just for relapse (state 1-state 2) and death hazard with a relapse (state 2-state 3).
  
  
  CONCLUSIONS
  Most researchers take account of assumptions such as Markov and time homogeneity in modeling transition rates. These assumptions can make the multi-state model simpler but if these assumptions are not made, they will lead to incorrect inferences and improper fitting.
authors: Department of Epidemiology and Biostatistics, Tehran University of Medical Sciences, Tehran, Iran E-mail : mahmoodim@tums.ac.ir.
authors: Zare
authors: Z
authors: Ali
authors: Mahmoodi
authors: M
authors: Mahmood
authors: Mohammad
authors: M
authors: Kazem
authors: Zeraati
authors: Z
authors: Hojjat
authors: Hosseini
authors: H
authors: Mostafa
authors: Holakouie Naieni
authors: HN
authors: Kourosh
mesh_terms: D006801:Humans; D007492:Iran; D008390:Markov Chains; D015233:Models, Statistical; D009364:Neoplasm Recurrence, Local; D011379:Prognosis; D018570:Risk Assessment / Q000379:methods; D013274:Stomach Neoplasms / Q000401:mortality* / Q000601:surgery*; D016019:Survival Analysis; D013995:Time