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Risks and Benefits of Severe Caloric Restriction—Reply
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In Reply: In response to Dr Mao, we recognize that anorexia nervosa is a serious and potentially life-threatening disease. We did not intend to imply that women should resort to anorexia as a measure of preventing breast cancer. Understanding the role of caloric restriction in the etiology of cancer, particularly breast cancer, is important for disentangling the puzzle of breast-cancer causation.
We do not share Mao's concern about competing rates. The analytic model used prevents such bias since it is based on a person-time denominator. A cohort member only contributes person-time at risk until she is censored from the analysis (due to a diagnosis of breast cancer, emigration, death, or the end of follow-up, whichever occurs first). If the risk of dying prematurely was associated with an excess risk of breast cancer, our results could have been biased; however, there is no known biological mechanism to support this hypothesis.
Karin B. Michels, ScD, MSc, MPH
kmichels@rics.bwh.harvard.edu
Brigham and Women's Hospital
Harvard Medical School
Boston, Mass
Anders Ekbom, MD, PhD
Karolinska Institute
Stockholm, Sweden
Letters Section Editor: Stephen J. Lurie, MD, PhD, Senior Editor.
JAMA. 2004;291:2704.
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