Advantages and disadvantages of observational and

Advantages and disadvantages
of observational and
experimental studies for diabetes
Sarah Wild, University of Edinburgh
BIRO Academy 2nd Residential
January 2011
Hierarchy of research evidence
Advantages of trials
Limitations of trials
Advantages of observational studies
Limitations of observational studies
Levels of evidence
for interventions
Evidence obtained from a systematic review of all
relevant randomised trials.
Evidence obtained from at least one properlydesigned randomised controlled trial.
Evidence from well-controlled trials that are not
randomised; or well-designed cohort or case-control
studies; or multiple time series (with or without the
Opinions of respected authorities; based on clinical
experience; descriptive studies; or reports of expert
Levels of evidence for
anecdote-based medicine
Level I: Bearded old professor
Level II: Doctor with honest face
Level III: Researcher with mad stare
Level IV: Health service manager with a
financial crisis
Benefits of randomisation
• Minimises confounding - known and
unknown potential confounders that
influence outcome are evenly distributed
between study groups
– reduces bias
– guarantees treatment assignment will not be
based on patients’ prognosis
Different effects of beta-carotene
intake in cohort studies and trials
Source: Egger and Davey Smith BMJ 1998; 316 : 140
Bias in RCTs
Bias = systematic deviation from the truth
Can underestimate or overestimate
effects of an intervention
• Selection/ allocation
• Ascertainment/ loss to follow-up
• Non-compliance
• Publication
Selection bias and
generalisibility of trials
• older adults, women and ethnic minorities often
under-represented in RCTs
• RCTs are often performed in highly selected
patient populations, eg those with typical
features of a disease, without co-morbidities or
those most likely to respond to the intervention
• A median of 4% of participants with current
asthma (range 0–36%) met the eligibility criteria
for 17 major asthma RCTs
Travers et al Thorax 2007;62:219-223
Comparison of trial and Lothian
population based register data
Age Duration
Lothian T2
Lothian T2
Ascertainment bias
Bias from loss to follow-up
• Occurs if people in one arm of trial are
reviewed more frequently and outcomes
are identified earlier and/or more
• Can result in lead time bias (ie apparent
increase in survival following earlier
diagnosis in one group)
• Differences in completeness of follow-up
between arms of trials may bias results
Efficacy vs effectiveness
• Not all people will use treatment as
• May be differences between those that
continue with allocated treatment and
those that don’t
• Exclusion of those who are not treated as
planned introduces bias
• Intention-to-treat analyses used to
preserve randomisation and reduce bias
Effect of non-compliance
• Non-compliance decreases power of study
• Non-compliers differ from compliers eg in
Physicians Health Study poor adherence
(taking < 50% of study tablets) was
associated with cigarette smoking, obesity,
lack of exercise, and history of angina
• In the placebo group better adherence was
strongly associated with decreased risk of
Publication bias – funnel plots
ACEI/ ARB & risk of T2DM
Source: Gillespie et al Diabetes Care 2005; 28 : 2261-2266
Maintaining randomisation
• Principle 1 (Intention to treat)
– Once a patient is randomised, his or her data should
be analysed in the group randomised to - even if they
discontinue, never receive treatment, or crossover.
• Principle 2 (adequate follow-up)
– “5-and-20 rule of thumb”
– 5% probably leads to little bias
– >20% poses serious threats to validity
Advantages of RCTs
• Provide strongest and most direct
epidemiologic evidence for causality
• Non-blinded RCTs may overestimate
treatment effects eg estimates of effect
from trials with inadequately concealed
allocation have been 40% larger than
clinical trials with adequately concealed
random allocation
Disadvantages of RCTs
• More difficult to design and conduct than
observational studies
– ethical issues
– feasibility
– costs
• Still some risk of bias and generalisibility
often limited
• Not suitable for all research questions
Limitations of trial design
Trials may be
• Unnecessary eg very effective intervention and
confounding unlikely to explain effects (eg
insulin for T1DM)
• Inappropriate eg measurement of infrequent
adverse outcomes, distant events
• Impossible eg ethical issues if outcome harmful,
widespread use of intervention, size of task
• Inadequate eg limited generalisibility – patients,
staff , care not representative
Source: Black N et al BMJ 1996; 312 : 1215
Checking trial quality
• In 1996, a group of clinical epidemiologists,
biostatisticians, and journal editors published
a statement called Consolidation of the
Standards of Reporting Trials (CONSORT)
• Aimed to improve the standard of written
reports of RCTs
• Includes a checklist of 25 items and a flow
• Revised statement produced 2010: see
Advantages of observational
studies over trials
Larger numbers
Longer follow-up
Likely to be more generalisable because
include more representative sample of
population (or whole population)
• Take place in normal health care settings
• Efficient use of available data
Disadvantages of observational
studies compared to trials
• Non-randomised allocation to exposure of
interest so strong likelihood of bias and
• Data more likely to be incomplete and of
poorer quality
• Outcomes less likely to be validated
Comparison of trials and primary
care database data
No adjustment for confounding
Adjustment for available confounders
Source: Tannen RL et al BMJ 2009; 338:b81
Attempting to reduce bias in
observational studies
• Adjusting for non-confounders
• Propensity matching - considers and
adjusts for the likelihood of a patient
receiving one treatment rather than the
other based on a number of pre-treatment
• Effective for some cases, but not all
Specific problems with metaanalysis of observational studies
• Confounding and selection bias often
distort the findings from observational
studies and there is a danger that metaanalyses of observational data produce
very precise but equally spurious results
• See beta carotene example
Source: Egger and Davey Smith BMJ 1998; 316 : 140
Different effects of beta-carotene
intake in cohort studies and trials
Source: Egger and Davey Smith BMJ 1998; 316 : 140
Quality of observational studies
• STROBE stands for an international,
collaborative initiative of epidemiologists,
methodologists, statisticians, researchers
and journal editors involved in the conduct
and dissemination of observational
studies, with the common aim of
STrengthening the Reporting of
OBservational studies in Epidemiology.
Examples of use of observational
Source: Brownstein JS et al Diabetes Care 2010 ; 33 : 526-531
Metformin and cancer incidence
• After adjusting for sex, age, BMI, A1C, deprivation,
smoking, and other drug use HR for cancer incidence
0.63 (0.53–0.75) among 4,085 Scottish metformin users
with 297 cancers compared with 4,085 non-metformin
users with 474 cancers, median times to cancer of 3.5
and 2.6 years,
• After adjusting for comorbidity, glargine and total insulin
doses, exposure to metformin among people with type 2
diabetes treated with insulin, was associated with
reduced incidence of cancer (OR 0.46 [0.25-0.85]
(Italian n=112, N=1340, FU 76 months)
Sources: Libby et al Diabetes Care 2009; 32:1620-1625
Monami et al Diabetes Care 2010; 33:1287-1290
Metformin and cancer mortality
• In patients taking metformin compared
with patients not taking metformin at
baseline, the adjusted HR for cancer
mortality 0.43 (95% CI 0.23–0.80) (Dutch
n=122, N=1353, FU 9.6 yrs).
• Cancer mortality in MF users similar to
general population
Source: Landman GWD et al Diabetes Care 2010; 33:322-326
Diabetes Rx and cancer incidence
Retrospective cohort study of 62,809 people in the UK who
developed diabetes >40 years of age, treated after 2000.
2106 people developed cancer
HR compared to MF monotherapy
• 1.08 (0.96-1.21) for MF+SU
• 1.36 (1.19-1.54) for SU monotherapy
• 1.42 (1.27-1.60) for insulin
HR compared to insulin and no MF
• 0.54 (0.43-0.66) for insulin +MF
HR compared to untreated DM
• 0.90 (0.79-1.03) for MF
Source: Currie et al Diabetologia 2009;52:1766-1777
Diabetes Rx and cancer mortality
• 10,309 new users for >1 year of metformin (MF) or
sulfonylureas (SU) 1991-1996 with an average follow-up
of 5.4 ± 1.9 years (means ± SD) identified from
Saskatchewan Health administrative databases. Mean
age 63.4 ± 13.3 years, 55% men.
• Cancer mortality over follow-up was 4.9% (162 of 3,340)
for SU monotherapy users, 3.5% (245 of 6,969) for MF
users, and 5.8% (84 of 1,443) for insulin users
After adjustment for age, sex, insulin use, co-morbidity HR
for cancer mortality compared with the MF cohort
• 1.3 [95% CI 1.1–1.6]; P = 0.012) for SU users
• 1.9 (95% CI 1.5–2.4; P < 0.0001) for insulin users
Source: Bowker et al Diabetes Care 2006: 29; 254-8
Were metformin users different?
• Scottish study: MF users younger, more likely to be
never smokers, higher BMI, higher HbA1c, less likely to
use insulin, more likely to use SU than comparison group
• Dutch: MF users shorter duration of DM, higher BMI,
higher CV risk, lower insulin and SU use than non-MF
• UK: MF users younger, more likely to be female, shortest
duration of diabetes, heavier, higher cholesterol, lower
HbA1c, lower co-morbidity (CVD and cancer)
• Canadian: SU users older with more men, MF users
younger, more likely to be female, longer duration of
treatment and more likely to receive insulin
Trials in progress
• ENERGY: weight loss intervention to
improve quality of life and reduce risk of
recurrence for women with early stage
breast cancer
• Phase III Randomized Trial of Metformin
Versus Placebo on Recurrence and
Survival in Early Stage Breast Cancer
Received: 29 Aug 2008
Accepted: 26 May 2009
Published online: 30 Jun 2009
Received: 5 Jun 2009
Accepted: 24 Jun 2009
Published online: 15 Jul 2009
Received: 26 May 2009
Accepted: 18 Jun 2009
Published online: 9 Jul 2009
Received: 19 May 2009
Accepted: 18 Jun 2009
Published online: 2 Jul 2009
Glargine and cancer –
observational data
Published Diabetologia Sept, 2009
All cancer
Breast cancer
Hemkens et al.
Unadj.: no difference
Dose adj.: increased risk
Not reported
Jonasson et al.
No difference
Increased risk
(only for glargine alone)
Increased risk in fixed cohort
and transition study (glargine
alone but not glargine + other
No effect in incident cohort;
Increased risk (only for
glargine alone) in fixed
and incident groups,
non-sig. increase in
transition cohort
No difference
No difference
Colhoun et al.
Currie et al.
What do these studies tell us?
• Possible association between insulin and cancer
• Metformin appears to offer protection
• Long acting insulin analogue therapy associated with
cancer in some studies
• Short timescale suggests effect on cancer progression
• Retrospective cohort studies are difficult to interpret
– effect of confounders
– reverse causation
– allocation bias/ confounding by indication
– dose information rarely available
Further considerations for glargine
• Small numbers (25 and 6 breast Ca in Swedish and
Scottish studies respectively)
• No association between glargine and breast cancer
mortality in Swedish study
• No association for glargine with other malignancy
• Glargine exposure with other insulins not associated with
• In Scottish study glargine alone users were older, more
likely to have T2, be on OHAs, have high BP, higher
HbA1c, had shorter duration of DM than other insulin
users.Significant effect of confounders – crude HR for all
cancers 2.6 and adjusted HR 1.7
• No adjustment for dose or duration of insulin use
Factors influencing diabetes
treatment/ cancer association
• Reverse causality – early symptoms of cancer may
influence treatment of diabetes
• Obesity: BMI/ adiposity/ fat distribution – MF more likley
to be used in overweight/obese but weight increases
with SU and insulin
• Glycaemic control
• Duration of diabetes and use of insulin
Diet including alcohol
Physical activity
Socio-economic status
Reproductive history
Cancer treatment (surgery, chemotherapy, radiotherapy)
Incident Cancers in Large Randomized
Trials of Glucose Lowering.
Gerstein, H. C. JAMA 2010;303:446-447
Intensive glycaemic control trials
and cancer risk – meta-analysis
• 222 Ca deaths in 53,892 person-years among
intensively treated group and 155 Ca deaths in 38,743
person-years among usual care group
• Risk ratios for cancer mortality:
1.00 (95% CI 0.81-1.24) for all
1.03 (95% CI 0.83-1.29) if exclude UKPDS MF
• 357 incident Ca in 47,974 person-years among
intensively treated group and 380 events in 45,009
person-years in control arm
• Risk ratio for cancer incidence: 0.91 (95% CI 0.79-1.05)
Source: Johnson et al Diabetologia. 2011 Jan;54(1):25-31
Mean weight increases in trials of
intensive therapy to achieve
glycaemic control
Mean weight difference in intensive
(detail of weight comparison)
(3 years)
3.1 kg (greater mean weight gain)
0.7 kg (greater mean weight during
2.9 kg (greater mean weight gain)
conventional therapy)
4 kg (higher weight at follow up)
Aetiology of diabetes and cancer
Poor control
Good control
Beta cell failure
• Well conducted RCTs are the optimum study
design to test beneficial effects of treatment in a
selected populations because they have the
lowest risk of bias and confounding
• Observational studies have a role to play in
– generating hypotheses
– investigating drug effectiveness in real world
– describing rare, adverse outcomes in large
BUT role of bias and confounding should be
considered in the interpretation of findings
Further reading
• A proposed method of bias adjustment for meta-analyses of
published observational studies Thompson S et al Int. J. Epidemiol.
(2010) doi: 10.1093/ije/dyq248
• Advancing the Science for Active Surveillance: Rationale and
Design for the Observational Medical Outcomes Partnership Annals
of Internal Medicine 2010 153:600-606
• When are observational studies as credible as randomised trials?
Vandenbroucke JP. Lancet. 2004;363:1728-31.
• Real-world effectiveness of new medicines should be evaluated by
appropriately designed clinical trials Freemantle and Strack J Clin
Epi 2010 63:1053-1058
• Commentaries on glargine papers eg Gale and Smith (Diabetologia
2009) Smeeth and Pocock (Lancet 2009)