Cohort vs case-control studies on night shift work and cancer risk: the importance of exposure assessment

Abstract It is a general assumption that the prospective cohort study design is the gold standard approach and is superior to the case-control study design in epidemiology. However, there may be exceptions if the exposure is complex and requires collection of detailed information on many different aspects. Night-shift work, which impairs circadian rhythms, is an example of such a complex occupational exposure and may increase the risks of breast, prostate, and colorectal cancer. So far, for logistical reasons, investigators in cohort studies have assessed shift work rather crudely, lacking information on full occupational history and relevant shift-work metrics, and have presented mostly null findings. On the other hand, most cancer case-control studies have assessed the lifetime occupational histories of participants, including collection of detailed night-shift work metrics (e.g., type, duration, intensity), and tend to show positive associations. In this commentary, we debate why cohort studies with weak exposure assessment and other limitations might not necessarily be the preferred or less biased approach in assessing the carcinogenicity of night-shift work. Furthermore, we propose that risk-of-bias assessment and comparison of associations between studies with low versus high risks of bias be considered in future synthesis of the evidence.