Emilsson L, Garcia-Albeniz X, Logan RW, Caniglia EC, Kalager M, Hernan MA. Examining bias in studies of statin treatment and survival in patients with cancer. JAMA Oncol. 2018 Jan 1;4(1):63-70. doi: 10.1001/jamaoncol.2017.2752

IMPORTANCE: Patients with cancer who use statins appear to have a substantially better survival than nonusers in observational studies. However, this inverse association between statin use and mortality may be due to selection bias and immortal-time bias.

OBJECTIVE: To emulate a randomized trial of statin therapy initiation that is free of selection bias and immortal-time bias.

DESIGN, SETTING, AND PARTICIPANTS: We used observational data on 17 372 patients with cancer from the Surveillance, Epidemiology, and End Results (SEER)-Medicare database (2007-2009) with complete follow-up until 2011. The SEER-Medicare database links 17 US cancer registries and claims files from Medicare and Medicaid in 12 US states. We included individuals with a new diagnosis of colorectal, breast, prostate, or bladder cancer who had not been prescribed statins for at least 6 months before the cancer diagnosis. Individuals were duplicated, and each replicate was assigned to either the strategy "statin therapy initiation within 6 months after diagnosis" or "no statin therapy initiation." Replicates were censored when they stopped following their assigned strategy, and the potential selection bias was adjusted for via inverse-probability weighting. Hazard ratios (HRs), cumulative incidences, and risk differences were calculated for all-cause mortality and cancer-specific mortality. We then compared our estimates with those obtained using the same analytic approaches used in previous observational studies.

EXPOSURES: Statin therapy initiation within 6 months after cancer diagnosis.

MAIN OUTCOMES AND MEASURES: Cancer-specific and all-cause mortality using SEER-Medicare data and data from previous studies.

Of the 17 372 patients whose data were analyzed, 8440 (49%) were men, and 8932 (51%) were women (mean [SD] age, 76.4 [7.4] years; range, 66-115 years). The adjusted HR (95% CI) comparing statin therapy initiation vs no initiation was 1.00 (0.88-1.15) for cancer-specific mortality and 1.07 (0.93-1.21) for overall mortality. Cumulative incidence curves for both groups were almost overlapping (the risk difference never exceeded 0.8%). In contrast, the methods used by prior studies resulted in an inverse association between statin use and mortality (pooled hazard ratio 0.69).

CONCLUSIONS AN DRELEVANCE: After using methods that are not susceptible to selection bias from prevalent users and to immortal time bias, we found that initiation of therapy with statins within 6 months after cancer diagnosis did not appear to improve 3-year cancer-specific or overall survival.

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