Healthy worker survivor bias in the Colorado Plateau uranium miners cohort

Am J Epidemiol. 2015 May 15;181(10):762-70. doi: 10.1093/aje/kwu348. Epub 2015 Apr 1.


Cohort mortality studies of underground miners have been used to estimate the number of lung cancer deaths attributable to radon exposure. However, previous studies of the radon-lung cancer association among underground miners may have been subject to healthy worker survivor bias, a type of time-varying confounding by employment status. We examined radon-mortality associations in a study of 4,124 male uranium miners from the Colorado Plateau who were followed from 1950 through 2005. We estimated the time ratio (relative change in median survival time) per 100 working level months (radon exposure averaging 130,000 mega-electron volts of potential α energy per liter of air, per working month) using G-estimation of structural nested models. After controlling for healthy worker survivor bias, the time ratio for lung cancer per 100 working level months was 1.168 (95% confidence interval: 1.152, 1.174). In an unadjusted model, the estimate was 1.102 (95% confidence interval: 1.099, 1.112)-39% lower. Controlling for this bias, we estimated that among 617 lung cancer deaths, 6,071 person-years of life were lost due to occupational radon exposure during follow-up. Our analysis suggests that healthy worker survivor bias in miner cohort studies can be substantial, warranting reexamination of current estimates of radon's estimated impact on lung cancer mortality.

Keywords: G-estimation; cohort studies; dose-response; lung neoplasms; mortality; occupational exposure; radon; structural nested model.

Publication types

  • Research Support, N.I.H., Extramural

MeSH terms

  • Adult
  • Aged
  • Bias*
  • Cohort Studies
  • Colorado / epidemiology
  • Dose-Response Relationship, Radiation
  • Humans
  • Lung Neoplasms / etiology
  • Lung Neoplasms / mortality*
  • Male
  • Middle Aged
  • Mining*
  • Occupational Diseases / mortality*
  • Radon / adverse effects*
  • Survivors
  • Uranium*


  • Uranium
  • Radon