ASSIGNMENT

COHORT VS CASE CAONTROL

SUBJECT: EPIDEMIOLOGY AND RESEARCH

SUBMITTED BY IRSHAD AHMED

SUBMITTED TO DR REEMA ASLAM

Cohort Studies :
cohort study is a type of epidemiological study in which a group of people with a common
characteristic is followed over time to find how many reach a certain health outcome of interest
(disease, condition, event, death, or a change in health status or behavior). A cohort is defined as
a group of persons, usually 100 or more in size, who share a common characteristic, e.g.
smokers, workers in a lead smelter, people born in the same year, or all enrollees of a specific
health insurance plan Cohort studies compare an exposed group of individuals to an unexposed
(or less exposed) group of individuals to determine if the outcome of interest is associated with
exposure. There are two types of cohort studies: prospective and retrospective (or historical)
cohorts. Prospective studies follow a cohort into the future for a health outcome, while
retrospective studies trace the cohort back in time for exposure information after the outcome has
occurred. Both types of cohort studies are also referred to as longitudinal or follow-up studies.
(Dr. Carl M. Shy, Epidemiology 1994- 2001,)

Advantages of a cohort study

A cohort study directly measure the risk and of a health outcome occurrence over time Cohort
studies are an efficient means of studying exposures (e.g. gasoline fumes, as discussed in the
next paragraph), in which contrast to case-control studies, tend to be better for rare outcomes.
Cohort studies allow the investigator to assess multiple outcomes of single a single exposure:
A cohort study would be the most efficient means of studying the effects of long-term
exposure to gasoline fumes. The cohort would consist of individuals who are exposed daily to
gasoline fumes (auto mechanics, gas station attendants, sea crewman on tankers, etc.). By
studying this group
of individuals, the investigator can better determine the direct effects of long-term, regular
gasoline inhalation. Also, by conducting a cohort study, investigator could determine if gasoline
inhalation causes many different health outcomes (e.g. different types of cancer and respiratory
illness) (Lippincott Williams and Wilkins, 1998)

Additional advantages of cohort studies

cohort studies establish temporal relationships between exposure and outcome. Exposure clearly
precedes outcome because the population under study at is free of the outcome of interest.
Cohort studies avoid recall bias (as the exposure is determined the outcome, one's health
outcome or disease state won't affect accurately one recalls exposure levels), as well survival
bias (duration of disease influencing exposure measurements). Therefore, cohort studies are the

Disadvantages of cohort studies

 Cohort studies require large sample sizes, especially when the is rare, defined as less than 1
event per 1000 years (e.g., all specific cancers). Therefore, studies tend to be expensive and
When there are losses to follow-up (individuals leave the cohort before the end of follow-up)
biases occur. Thus, individuals who leave the prematurely may have a different baseline risk than
members who remain in the cohort throughout the length of follow-up. Therefore, the study may
not generalizable to the original target population, but those who remained under investigation
the length of the study. Also, any differences in quality of measurement of exposure or disease
exposed and non-exposed cohorts may information bias and thereby distort the result. (The
University of North Carolina at Chapel Hill, Fundamentals of Epidemiology course lectures,
2009- 2013)

Case-control study

A case-control study is a type of observational study commonly used to look at factors associated
with diseases or outcomes. The case-control study starts with a group of cases, which are the
individuals who have the outcome of interest. The researcher then tries to construct a second
group of individuals called the controls, who are similar to the case individuals but do not have
the outcome of interest. The researcher then looks at historical factors to identify if some
exposure(s) is/are found more commonly in the cases than the controls. If the exposure is found
more commonly in the cases than in the controls, the researcher can hypothesize that the
exposure may be linked to the outcome of interest.

For example, a researcher may want to look at the rare cancer Kaposi's sarcoma. The researcher
would find a group of individuals with Kaposi's sarcoma (the cases) and compare them to a
group of patients who are similar to the cases in most ways but do not have Kaposi's sarcoma
(controls). The researcher could then ask about various exposures to see if any exposure is more
common in those with Kaposi's sarcoma (the cases) than those without Kaposi's sarcoma (the
controls). The researcher might find that those with Kaposi's sarcoma are more likely to have
HIV, and thus conclude that HIV may be a risk factor for the development of Kaposi's sarcoma.

Advantages

There are many advantages to case-control studies. First, the case-control approach allows for
the study of rare diseases. If a disease occurs very infrequently, one would have to follow a large
group of people for a long period of time to accrue enough incident cases to study. Such use of
resources may be impractical, so a case-control study can be useful for identifying current cases
and evaluating historical associated factors. For example, if a disease developed in 1 in 1000
people per year (0.001/year) then in ten years one would expect about 10 cases of a disease to
exist in a group of 1000 people. If the disease is much rarer, say 1 in 1,000,0000 per year
(0.0000001/year) this would require either having to follow 1,000,0000 people for ten years or
1000 people for 1000 years to accrue ten total cases. As it may be impractical to follow
1,000,000 for ten years or to wait 1000 years for recruitment, a case-control study allows for a
more feasible approach.

Second, the case-control study design makes it possible to look at multiple risk factors at once. In
the example above about Kaposi's sarcoma, the researcher could ask both the cases and controls
about exposures to HIV, asbestos, smoking, lead, sunburns, aniline dye, alcohol, herpes, human
papillomavirus, or any number of possible exposures to identify those most likely associated
with Kaposi's sarcoma.

Case-control studies can also be very helpful when disease outbreaks occur, and potential links
and exposures need to be identified. This study mechanism can be commonly seen in food-
related disease outbreaks associated with contaminated products, or when rare diseases start to
increase in frequency, as has been seen with measles in recent years.

Because of these advantages, case-control studies are commonly used as one of the first studies
to build evidence of an association between exposure and an event or disease.

In a case-control study, the investigator can include unequal numbers of cases with controls such
as 2:1 or 4:1 to increase the power of the study.

Disadvantages and Limitations

The most commonly cited disadvantage in case-control studies is the potential for recall bias.
Recall bias in a case-control study is the increased likelihood that those with the outcome will
recall and report exposures compared to those without the outcome. In other words, even if both
groups had exactly the same exposures, the participants in the cases group may report the
exposure more often than the controls do. Recall bias may lead to concluding that there are
associations between exposure and disease that do not, in fact, exist. It is due to subjects'
imperfect memories of past exposures. If people with Kaposi's sarcoma are asked about exposure
and history (e.g., HIV, asbestos, smoking, lead, sunburn, aniline dye, alcohol, herpes, human
papillomavirus), the individuals with the disease are more likely to think harder about these
exposures and recall having some of the exposures that the healthy controls.

Case-control studies, due to their typically retrospective nature, can be used to establish
a correlation between exposures and outcomes, but cannot establish causation. These studies
simply attempt to find correlations between past events and the current state.

When designing a case-control study, the researcher must find an appropriate control group.
Ideally, the case group (those with the outcome) and the control group (those without the
outcome) will have almost the same characteristics, such as age, gender, overall health status,
and other factors. The two groups should have similar histories and live in similar environments.
If, for example, our cases of Kaposi's sarcoma came from across the country but our controls
were only chosen from a small community in northern latitudes where people rarely go outside
or get sunburns, asking about sunburn may not be a valid exposure to investigate. Similarly, if all
of the cases of Kaposi's sarcoma were found to come from a small community outside a battery
factory with high levels of lead in the environment, then controls from across the country with
minimal lead exposure would not provide an appropriate control group. The investigator must
put a great deal of effort into creating a proper control group to bolster the strength of the case-
control study as well as enhance their ability to find true and valid potential correlations between
exposures and disease states.

Similarly, the researcher must recognize the potential for failing to identify confounding
variables or exposures, introducing the possibility of confounding bias, which occurs when a
variable that is not being accounted for that has a relationship with both the exposure and
outcome. This can cause us to accidentally be studying something we are not accounting for but
that may be systematically different between the groups.

References
Dr. Carl M. Shy, Epidemiology 160/600 Introduction to Epidemiology for Public Health course
lectures, 1994- 2001, The University of North Carolina at Chapel Hill, Department of
Epidemiology
Rothman KJ, Greenland S. Modern Epidemiology. Second Edition. Philadelphia: Lippincott
Williams and Wilkins, 1998.
The University of North Carolina at Chapel Hill, Department of Epidemiology Courses:
Epidemiology 710, Fundamentals of Epidemiology course lectures, 2009- 2013, and
Epidemiology 718, Epidemiologic Analysis of Binary Data course lectures, 2009-2013.
Tenny, S., Kerndt, C. C., & Hoffman, M. R. (2023). Case Control Studies. In StatPearls.
StatPearls Publishing.
Setia MS. Methodology Series Module 2: Case-control Studies. Indian J Dermatol. 2016 Mar-
Apr;61(2):146-51. - PMC - PubMed

Sedgwick P. Bias in observational study designs: case-control studies. BMJ. 2015 Jan
30;350:h560. - PubMed

Groenwold RHH, van Smeden M. Efficient Sampling in Unmatched Case-Control Studies When
the Total Number of Cases and Controls Is Fixed. Epidemiology. 2017 Nov;28(6):834-837. -
PubMed