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J Thorac Cardiovasc Surg 2008;135:457-459
© 2008 The American Association for Thoracic Surgery

Letter to the Editor

Comment on the "actual" problem editorial

William N. Anderson, PhD*

Lake Forest, CA 92630

The first 300 words of the full text of this article appear below.

To the Editor:

The recent editorial by Bodnar and Blackstone1Go suggests that the so-called "actual" analysis has been misused at times and makes suggestions for limiting its future use. I generally agree with the editorial.

However, the method is mathematically valid and does have some important uses. I fear that in overreacting to some misuses we run the risk of throwing out the baby with the bath water. In this letter, I discuss some of the mathematical background and some applications in which use of competing risks analysis is critical for proper understanding of a clinical situation.

I agree with the editorial that the term "actual" is potentially misleading and that other terminology should be used. The general area of analysis is often referred to as "competing risks" analysis, and the term "cumulative incidence" seems to be widely accepted in this area. I agree with the suggestion that the term "cumulative incidence" be used.

One point that must be made is that competing risks analysis rests on a completely sound mathematical footing, and cumulative incidence is a precisely defined mathematical concept. The general setting is that there are two (or more) competing risks. Each risk will have its own probability distribution, and the concept of the first event to be observed is precisely defined. Theoretical treatments are given in Kalbfleisch and Prentice2Go and Andersen and associates3Go; formula 4.4.19 of the latter reference includes a derivation of the standard error. A rather more readable treatment, which clearly illustrates the difference between Kaplan–Meier (actuarial) analysis and competing risks analysis, is given by Gooley and colleagues.4Go

The methodology of competing risks is standard in many medical areas. The article by Gaynor and coworkers5Go discusses an oncology example with three competing risks; a standard error formula is given, but it is more difficult . . . [Full Text of this Article]


Related Article

Reply to the Editor
Endre Bodnar and Eugene H. Blackstone
J. Thorac. Cardiovasc. Surg. 2008 135: 460. [Extract] [Full Text] [PDF]





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