# Long-term survival and the critical role of competing risks in pneumoconiosis: a large-scale retrospective cohort study

## TL;DR

This study shows that non-pneumoconiosis causes increasingly affect survival in pneumoconiosis patients, requiring updated risk models and comprehensive care.

## Contribution

The study introduces a Fine–Gray model-based nomogram to accurately account for competing risks in pneumoconiosis survival analysis.

## Key findings

- Non-pneumoconiosis-related death became a dominant risk over time in pneumoconiosis patients.
- Traditional Cox models overestimate risk effects compared to the Fine–Gray model.
- A prognostic nomogram showed high accuracy in predicting survival outcomes.

## Abstract

The extension of survival in patients with pneumoconiosis has led to a shifting mortality spectrum where non-pneumoconiosis causes increasingly act as competing risks. Traditional survival analyses frequently ignore these competing events, potentially biasing prognostic estimates.

We conducted a retrospective study of 18,064 patients with pneumoconiosis diagnosed between 1960 and 2024 in Jiangsu Province. The Fine–Gray model was used to identify independent predictors of pneumoconiosis-related death while accounting for competing mortality. We compared this evidence with the standard Cox proportional hazards model and established a prognostic nomogram.

The cumulative incidence of non-pneumoconiosis-related death progressively surpassed that of pneumoconiosis-related death during long-term follow-up. Older age at diagnosis, silicosis, an earlier era of diagnosis, and advanced baseline stage were identified as independent risk factors. The traditional Cox model overestimated risk effects for variables with differential impacts on competing outcomes. Subgroup analyses showed a significant interaction between disease type and stage regarding competing mortality risk. Specifically, patients with Stage II silicosis exhibited higher systemic vulnerability compared with those with coal workers’ pneumoconiosis. The constructed nomogram demonstrated high discrimination and calibration.

Non-pneumoconiosis-related death constitutes a critical competing risk that substantially affects the long-term survival outcomes of patients with pneumoconiosis. The Fine–Gray model provides accurate risk stratification by correcting for potential overestimation bias. Clinical management strategies must shift from singular pulmonary care to comprehensive health management that addresses comorbidities to improve overall survival outcomes.