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The Cox proportional hazard model is being used extensively in oncology in studying the relationship between survival times and prognostic factors. The main question that needs to be addressed with respect to the applicability of the Cox PH model is whether the proportional hazard assumption is met. Failure to justify the subject assumption will lead to misleading results. In addition, identifying the correct functional form of the continuous covariates is an important aspect in the development of a Cox proportional hazard model. The purpose of this study is to develop an extended Cox regression model for breast cancer survival data which takes non-proportional hazards and non-linear effects that exist in prognostic factors into consideration. Non-proportional hazards and non-linear effects are detected using methods based on residuals. An extended Cox model with non-linear effects and time-varying effects is proposed to adjust the Cox proportional hazard model. Age and tumor size were found to have nonlinear effects. Progesterone receptor assay status and age violated the proportional hazard assumption in the Cox model. Quadratic effect of age and progesterone receptor assay status had hazard ratio that changes with time. We have introduced a statistical model to overcome the presence of the proportional hazard assumption violation for the Cox proportional hazard model for breast cancer data. The proposed extended model considers the time varying nature of the hazard ratio and non-linear effects of the covariates. Our improved Cox model gives a better insight on the hazard rates associated with the breast cancer risk factors.

A Statistical Model with Non-Linear Effects and Non-Proportional Hazards for Breast Cancer Survival Analysis