title: Improved Method to Stratify Elderly Patients With Cancer at Risk for Competing Events.
abstract: OBJECTIVE
  To compare a novel generalized competing event (GCE) model versus the standard Cox proportional hazards regression model for stratifying elderly patients with cancer who are at risk for competing events.
  
  
  METHODS
  We identified 84,319 patients with nonmetastatic prostate, head and neck, and breast cancers from the SEER-Medicare database. Using demographic, tumor, and clinical characteristics, we trained risk scores on the basis of GCE versus Cox models for cancer-specific mortality and all-cause mortality. In test sets, we examined the predictive ability of the risk scores on the different causes of death, including second cancer mortality, noncancer mortality, and cause-specific mortality, using Fine-Gray regression and area under the curve. We compared how well models stratified subpopulations according to the ratio of the cumulative cause-specific hazard for cancer mortality to the cumulative hazard for overall mortality (ω) using the Akaike Information Criterion.
  
  
  RESULTS
  In each sample, increasing GCE risk scores were associated with increased cancer-specific mortality and decreased competing mortality, whereas risk scores from Cox models were associated with both increased cancer-specific mortality and competing mortality. GCE models created greater separation in the area under the curve for cancer-specific mortality versus noncancer mortality (P < .001), indicating better discriminatory ability between these events. Comparing the GCE model to Cox models of cause-specific mortality or all-cause mortality, the respective Akaike Information Criterion scores were superior (lower) in each sample: prostate cancer, 28.6 versus 35.5 versus 39.4; head and neck cancer, 21.1 versus 29.4 versus 40.2; and breast cancer, 24.6 versus 32.3 versus 50.8.
  
  
  CONCLUSIONS
  Compared with standard modeling approaches, GCE models improve stratification of elderly patients with cancer according to their risk of dying from cancer relative to overall mortality.
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Ruben
authors.initials: R
authors.lastname: Carmona
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Kaveh
authors.initials: K
authors.lastname: Zakeri
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Garrett
authors.initials: G
authors.lastname: Green
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Lindsay
authors.initials: L
authors.lastname: Hwang
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Sachin
authors.initials: S
authors.lastname: Gulaya
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Beibei
authors.initials: B
authors.lastname: Xu
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Rohan
authors.initials: R
authors.lastname: Verma
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Casey W
authors.initials: CW
authors.lastname: Williamson
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Daniel P
authors.initials: DP
authors.lastname: Triplett
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Brent S
authors.initials: BS
authors.lastname: Rose
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Hanjie
authors.initials: H
authors.lastname: Shen
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: Florin
authors.initials: F
authors.lastname: Vaida
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA.
authors.forename: James D
authors.initials: JD
authors.lastname: Murphy
authors.affiliation: Ruben Carmona, Kaveh Zakeri, Garrett Green, Sachin Gulaya, Beibei Xu, Rohan Verma, Casey W. Williamson, Daniel P. Triplett, Hanjie Shen, James D. Murphy, and Loren K. Mell, University of California, San Diego, La Jolla; Florin Vaida, University of California San Diego Medical Center, San Diego, CA; Lindsay Hwang, Case Western Reserve University, Cleveland, OH; and Brent S. Rose, Brigham and Women's Hospital and Dana-Farber Cancer Institute, Boston, MA. lmell@ucsd.edu.
authors.forename: Loren K
authors.initials: LK
authors.lastname: Mell
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001943:Breast Neoplasms / Q000150:complications / Q000401:mortality; D002423:Cause of Death; D005260:Female; D006258:Head and Neck Neoplasms / Q000150:complications / Q000401:mortality; D006801:Humans; D008297:Male; D006278:Medicare; D015233:Models, Statistical; D009369:Neoplasms / Q000150:complications* / Q000401:mortality*; D016016:Proportional Hazards Models; D011471:Prostatic Neoplasms / Q000150:complications / Q000401:mortality; D018570:Risk Assessment; D012307:Risk Factors; D018426:SEER Program; D014481:United States / Q000453:epidemiology