The competing risk of death and selective survival cannot fully explain the inverse cancer‐dementia association

Abstract Introduction We evaluated whether competing risk of death or selective survival could explain the reported inverse association between cancer history and dementia incidence (incidence rate ratio [IRR] ≈ 0.62‐0.85). Methods A multistate simulation model of a cancer‐ and dementia‐free cohort of 65‐year‐olds was parameterized with real‐world data (cancer and dementia incidence, mortality), assuming no effect of cancer on dementia (true IRR = 1.00). To introduce competing risk of death, cancer history increased mortality. To introduce selective survival, we included a factor (prevalence ranging from 10% to 50%) that reduced cancer mortality and dementia incidence (IRRs ranged from 0.30 to 0.90). We calculated IRRs for cancer history on dementia incidence in the simulated cohorts. Results Competing risk of death yielded unbiased cancer‐dementia IRRs. With selective survival, bias was small (IRRs = 0.89 to 0.99), even under extreme scenarios. Discussion The bias induced by selective survival in simulations was too small to explain the observed inverse cancer‐dementia link, suggesting other mechanisms drive this association.