Adjusting survival estimates for differential loss to follow-up by race and ethnicity: a SEER analysis
Abstract
BACKGROUND: Apparent survival advantages for Hispanic and non-Hispanic Asian and Pacific Islander individuals, often labeled the "Hispanic paradox" or "healthy immigrant effect," have been reported for multiple cancers compared with non-Hispanic White and non-Hispanic Black persons. Higher proportions of loss to follow-up among Hispanic and non-Hispanic Asian and Pacific Islander persons overestimate survival because of informative censoring. We developed a sensitivity analysis-based method to address potential impacts of differential loss to follow-up. METHODS: We estimated 5-year age-standardized cancer-specific survival for non-Hispanic White (reference), non-Hispanic Black, Hispanic, non-Hispanic Asian and Pacific Islander, Hispanic, and non-Hispanic American Indian or Alaska Native persons diagnosed between 2005 and 2019 in 22 Surveillance, Epidemiology, and End Results Program registries. Persons alive with less than 5 years or maximum possible follow-up were classified as lost to follow-up. For each cancer stage-race and ethnicity combination, for cases lost to follow-up exceeding levels for non-Hispanic White persons, we modeled 2 plausible scenarios relative to survival of non-Hispanic White patients: (1) "lower" survival and (2) "higher" survival. Across 1000 simulations, we constructed a sensitivity interval spanning the average lower 95% confidence bound of "lower" survival to the average upper 95% confidence bound of "higher" survival. RESULTS: Loss to follow-up was higher for Hispanic and non-Hispanic Asian and Pacific Islander persons and Hispanic individuals across cancer sites (range = 2.2%-20.7%) than for non-Hispanic White persons (range = 0.4%-5.4%). Sensitivity intervals were consistently wider than standard 95% CIs. After accounting for differential loss to follow-up, previously observed equivalent or higher survival disappeared for Hispanic and non-Hispanic Asian and Pacific Islander persons (eg, prostate cancer) and Hispanic persons (eg, lung cancer). CONCLUSIONS: Ignoring differential loss to follow-up overstates survival advantages among racial and ethnic minorities. Sensitivity analysis revealed that reported survival advantages are artifacts of higher loss to follow-up, underscoring the need to address this censoring bias in population-based survival studies.
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BibTeX
@article{devasia2026adjusting,
title = {{Adjusting survival estimates for differential loss to follow-up by race and ethnicity: a SEER analysis}},
author = {Theresa P Devasia and Paulo S Pinheiro and Mandi Yu},
journal = {JNCI Journal of the National Cancer Institute},
year = {2026},
month = jun,
doi = {10.1093/jnci/djag181},
url = {https://doi.org/10.1093/jnci/djag181},
note = {Public domain},
}
RIS
TY - JOUR
TI - Adjusting survival estimates for differential loss to follow-up by race and ethnicity: a SEER analysis
AU - Theresa P Devasia
AU - Paulo S Pinheiro
AU - Mandi Yu
PY - 2026
DA - 2026/06/04
JO - JNCI Journal of the National Cancer Institute
DO - 10.1093/jnci/djag181
UR - https://doi.org/10.1093/jnci/djag181
AB - BACKGROUND: Apparent survival advantages for Hispanic and non-Hispanic Asian and Pacific Islander individuals, often labeled the "Hispanic paradox" or "healthy immigrant effect," have been reported for multiple cancers compared with non-Hispanic White and non-Hispanic Black persons. Higher proportions of loss to follow-up among Hispanic and non-Hispanic Asian and Pacific Islander persons overestimate survival because of informative censoring. We developed a sensitivity analysis-based method to address potential impacts of differential loss to follow-up. METHODS: We estimated 5-year age-standardized cancer-specific survival for non-Hispanic White (reference), non-Hispanic Black, Hispanic, non-Hispanic Asian and Pacific Islander, Hispanic, and non-Hispanic American Indian or Alaska Native persons diagnosed between 2005 and 2019 in 22 Surveillance, Epidemiology, and End Results Program registries. Persons alive with less than 5 years or maximum possible follow-up were classified as lost to follow-up. For each cancer stage-race and ethnicity combination, for cases lost to follow-up exceeding levels for non-Hispanic White persons, we modeled 2 plausible scenarios relative to survival of non-Hispanic White patients: (1) "lower" survival and (2) "higher" survival. Across 1000 simulations, we constructed a sensitivity interval spanning the average lower 95% confidence bound of "lower" survival to the average upper 95% confidence bound of "higher" survival. RESULTS: Loss to follow-up was higher for Hispanic and non-Hispanic Asian and Pacific Islander persons and Hispanic individuals across cancer sites (range = 2.2%-20.7%) than for non-Hispanic White persons (range = 0.4%-5.4%). Sensitivity intervals were consistently wider than standard 95% CIs. After accounting for differential loss to follow-up, previously observed equivalent or higher survival disappeared for Hispanic and non-Hispanic Asian and Pacific Islander persons (eg, prostate cancer) and Hispanic persons (eg, lung cancer). CONCLUSIONS: Ignoring differential loss to follow-up overstates survival advantages among racial and ethnic minorities. Sensitivity analysis revealed that reported survival advantages are artifacts of higher loss to follow-up, underscoring the need to address this censoring bias in population-based survival studies.
SN - 0027-8874
SN - 1460-2105
ER -