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Updated: Jun 17, 2025

Establishing a Competing Risk Regression Nomogram Model for Survival Data
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Competing Risk Bias in Prognostic Models Predicting Hepatocellular Carcinoma Occurrence: Impact on Clinical

Hamish Innes1,2,3, Philip Johnson4, Scott A McDonald1,2

  • 1School of Health and Life Sciences, Glasgow Caledonian University, Glasgow, UK.

Gastro Hep Advances
|August 12, 2024
PubMed
Summary

Existing hepatocellular carcinoma (HCC) models overestimate risk by ignoring competing events. While overestimation occurs, its impact on HCC screening decisions for cirrhosis patients with cured hepatitis C is likely modest.

Keywords:
Competing RisksFine-GrayLiver CancerPrognosisRisk Stratification

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Area of Science:

  • Hepatology
  • Medical Statistics
  • Epidemiology

Background:

  • Hepatocellular carcinoma (HCC) is a significant concern in patients with cirrhosis and cured hepatitis C.
  • Existing prognostic models for HCC often fail to account for competing risks like non-HCC mortality.
  • This omission can lead to an overestimation of HCC probability.

Purpose of the Study:

  • To quantify the bias in HCC risk prediction caused by ignoring competing events.
  • To compare HCC probability estimates from models with and without competing risk adjustments in a specific patient cohort.

Main Methods:

  • Analysis of a nationwide cohort of 1629 patients with cirrhosis and cured hepatitis C from Scotland.
  • Development of two prognostic models: a Cox regression model (ignoring competing risks) and a Fine-Gray regression model (accounting for competing risks).
  • Comparison of 3-year HCC probability predictions between the two models for each patient.

Main Results:

  • A total of 82 HCC events and 159 non-HCC deaths were observed over an average follow-up of 3.8 years.
  • The mean predicted 3-year HCC probability was slightly higher with the Cox model (3.37%) compared to the Fine-Gray model (3.24%).
  • A minimal difference (<0.3%) was observed for 76% of patients; however, a discrepancy >2% occurred in 2.6% of patients with initially high HCC risk predictions.

Conclusions:

  • Prognostic models that disregard competing risks tend to overestimate the likelihood of developing HCC.
  • The magnitude and pattern of this overestimation suggest a potentially modest impact on clinical decisions regarding HCC screening in this population.