Nonparametric covariate adjustment in estimating hazard ratios

In randomized clinical trials with time‐to‐event outcomes, the hazard ratio is commonly used to quantify the treatment effect relative to a control. The Cox regression model is commonly used to adjust for relevant covariates to obtain more accurate estimates of the hazard ratio between treatment groups. However, it is well known that the treatment hazard ratio based on a covariate‐adjusted Cox regression model is conditional on the specific covariates and differs from the unconditional hazard ratio that is an average across the population. Therefore, covariate‐adjusted Cox models cannot be used when the unconditional inference is desired. In addition, the covariate‐adjusted Cox model requires the relatively strong assumption of proportional hazards for each covariate. To overcome these challenges, a nonparametric randomization‐based analysis of covariance method was proposed to estimate the covariate‐adjusted hazard ratios for multivariate time‐to‐event outcomes. However, empirical evaluations of the performance (power and type I error rate) of the method have not been studied. Although the method is derived for multivariate situations, for most registration trials, the primary endpoint is a univariate outcome. Therefore, this approach is applied to univariate outcomes, and performance is evaluated through a simulation study in this paper. Stratified analysis is also investigated. As an illustration of the method, we also apply the covariate‐adjusted and unadjusted analyses to an oncology trial. Copyright © 2015 John Wiley & Sons, Ltd.     

A Semi-parametric Bayesian Analysis of Survival Data Based on Lévy-driven Processes

In the presence of covariate information, the proportional hazards model is one of the most popular models. In this paper, in a Bayesian nonparametric framework, we use a Markov (Lévy-driven) process to model the baseline hazard rate. Previous Bayesian nonparametric models have been based on neutral to the right processes, which have a number of drawbacks, such as discreteness of the cumulative hazard function. We allow the covariates to be time dependent functions and develop a full posterior analysis via substitution sampling. A detailed illustration is presented.     

On proportional hazards assumption under the random effects models

The proportional hazards mixed-effects model (PHMM) was proposed to handle dependent survival data. Motivated by its application in genetic epidemiology, we study the interpretation of its parameter estimates under violations of the proportional hazards assumption. The estimated fixed effect turns out to be an averaged regression effect over time, while the estimated variance component could be unaffected, inflated or attenuated depending on whether the random effect is on the baseline hazard, and whether the non-proportional regression effect decreases or increases over time. Using the conditional distribution of the covariates we define the standardized covariate residuals, which can be used to check the proportional hazards assumption. The model checking technique is illustrated on a multi-center lung cancer trial.     

A dependent Dirichlet process model for survival data with competing risks

In this paper, we first propose a dependent Dirichlet process (DDP) model using a mixture of Weibull models with each mixture component resembling a Cox model for survival data. We then build a Dirichlet process mixture model for competing risks data without regression covariates. Next we extend this model to a DDP model for competing risks regression data by using a multiplicative covariate effect on subdistribution hazards in the mixture components. Though built on proportional hazards (or subdistribution hazards) models, the proposed nonparametric Bayesian regression models do not require the assumption of constant hazard (or subdistribution hazard) ratio. An external time-dependent covariate is also considered in the survival model. After describing the model, we discuss how both cause-specific and subdistribution hazard ratios can be estimated from the same nonparametric Bayesian model for competing risks regression. For use with the regression models proposed, we introduce an omnibus prior that is suitable when little external information is available about covariate effects. Finally we compare the models’ performance with existing methods through simulations. We also illustrate the proposed competing risks regression model with data from a breast cancer study. An R package “DPWeibull” implementing all of the proposed methods is available at CRAN.

     

An extended semiparametric model for short-term and long-term hazard ratios

In survival analysis, one way to deal with non-proportional hazards is to model short-term and long-term hazard ratios. The existing model of this nature has no control over how fast the hazard ratio is changing over time. We add a parameter to the existing model to allow the hazard ratio to change over time at different speed. A nonparametric maximum likelihood approach is used to estimate the model parameters. The existing model is a special case of the extended model when the speed parameter is 0, which leads naturally to a way of testing the adequacy of the existing model. Simulation results show that there can be substantial bias in the estimation of the short-term and long-term hazard ratio if the speed parameter is fixed incorrectly at 0 rather than estimated. The extended model is fitted to three real data sets to shed new insights, including the observation that converging hazards does not necessarily imply the odds are proportional.     

Frailty Models and Rank Tests

Connections are established between the theories of weighted logrank tests and of frailty models. These connections arise because omission of a balanced covariate from a proportional hazards model generally leads to a model with non-proportional hazards, for which the simple logrank test is no longer optimal. The optimal weighting function and the asymptotic relative efficiencies of the simple logrank test and of the optimally weighted logrank test relative to the adjusted test that would be used if the covariate values were known, are expressible in terms of the Laplace transform of the hazard ratio for the distribution of the omitted covariate. For example if this hazard ratio has a gamma distribution, the optimal test is a member of the G class introduced by Harrington and Fleming (1982). We also consider positive stable, inverse Gaussian, displaced Poisson and two-point frailty distribution. Results are obtained for parametric and nonparametric tests and are extended to include random censoring. We show that the loss of efficiency from omitting a covariate is generally more important than the additional loss due to misspecification of the resulting non-proportional hazards model as a proportional hazards model. However two-point frailty distributions can provide exceptions to this rule. Censoring generally increases the efficiency of the simple logrank test to the adjusted logrank test.     

A class of partially linear transformation models for recurrent gap times

In this article, we propose a general class of partially linear transformation models for recurrent gap time data, which extends the linear transformation models by incorporating non linear covariate effects and includes the partially linear proportional hazards and the partially linear proportional odds models as special cases. Both global and local estimating equations are developed to estimate the parametric and non parametric covariate effects, and the asymptotic properties of the resulting estimators are established. The finite-sample behavior of the proposed estimators is evaluated through simulation studies, and an application to a clinic study on chronic granulomatous disease is provided.     

A note on the asymptotic relative efficiency of estimators from the additive hazards model

In this note, the asymptotic variance formulas are explicitly derived and compared between the parametric and semiparametric estimators of a regression parameter and survival probability under the additive hazards model. To obtain explicit formulas, it is assumed that the covariate term including a regression coefficient follows a gamma distribution and the baseline hazard function is constant. The results show that the semiparametric estimator of the regression coefficient parameter is fully efficient relative to the parametric counterpart when the survival time and a covariate are independent, as in the proportional hazards model. Relative to a more realistic case of the parametric additive hazards model with a Weibull baseline, the loss of efficiency of the semiparametric estimator of survival probability is moderate.     

Partial orders with respect to continuous covariates and tests for the proportional hazards model

Several omnibus tests of the proportional hazards assumption have been proposed in the literature. In the two-sample case, tests have also been developed against ordered alternatives like monotone hazard ratio and monotone ratio of cumulative hazards. Here we propose a natural extension of these partial orders to the case of continuous and potentially time varying covariates, and develop tests for the proportional hazards assumption against such ordered alternatives. The work is motivated by applications in biomedicine and economics where covariate effects often decay over lifetime. The proposed tests do not make restrictive assumptions on the underlying regression model, and are applicable in the presence of time varying covariates, multiple covariates and frailty. Small sample performance and an application to real data highlight the use of the framework and methodology to identify and model the nature of departures from proportionality.     

Confidence intervals for the first crossing point of two hazard functions

The phenomenon of crossing hazard rates is common in clinical trials with time to event endpoints. Many methods have been proposed for testing equality of hazard functions against a crossing hazards alternative. However, there has been relatively few approaches available in the literature for point or interval estimation of the crossing time point. The problem of constructing confidence intervals for the first crossing time point of two hazard functions is considered in this paper. After reviewing a recent procedure based on Cox proportional hazard modeling with Box-Cox transformation of the time to event, a nonparametric procedure using the kernel smoothing estimate of the hazard ratio is proposed. The proposed procedure and the one based on Cox proportional hazard modeling with Box-Cox transformation of the time to event are both evaluated by Monte–Carlo simulations and applied to two clinical trial datasets.     

Fitting Cox Models with Doubly Censored Data Using Spline‐Based Sieve Marginal Likelihood

In some applications, the failure time of interest is the time from an originating event to a failure event while both event times are interval censored. We propose fitting Cox proportional hazards models to this type of data using a spline‐based sieve maximum marginal likelihood, where the time to the originating event is integrated out in the empirical likelihood function of the failure time of interest. This greatly reduces the complexity of the objective function compared with the fully semiparametric likelihood. The dependence of the time of interest on time to the originating event is induced by including the latter as a covariate in the proportional hazards model for the failure time of interest. The use of splines results in a higher rate of convergence of the estimator of the baseline hazard function compared with the usual non‐parametric estimator. The computation of the estimator is facilitated by a multiple imputation approach. Asymptotic theory is established and a simulation study is conducted to assess its finite sample performance. It is also applied to analyzing a real data set on AIDS incubation time.     

A nonparametric test to compare survival distributions with covariate adjustment

Summary.  The analysis of covariance is a technique that is used to improve the power of a k -sample test by adjusting for concomitant variables. If the end point is the time of survival, and some observations are right censored, the score statistic from the Cox proportional hazards model is the method that is most commonly used to test the equality of conditional hazard functions. In many situations, however, the proportional hazards model assumptions are not satisfied. Specifically, the relative risk function is not time invariant or represented as a log-linear function of the covariates. We propose an asymptotically valid k -sample test statistic to compare conditional hazard functions which does not require the assumption of proportional hazards, a parametric specification of the relative risk function or randomization of group assignment. Simulation results indicate that the performance of this statistic is satisfactory. The methodology is demonstrated on a data set in prostate cancer.     

Checking the Short‐Term and Long‐Term Hazard Ratio Model for Survival Data

Abstract. The short‐term and long‐term hazard ratio model includes the proportional hazards model and the proportional odds model as submodels, and allows a wider range of hazard ratio patterns compared with some of the more traditional models. We propose two omnibus tests for checking this model, based, respectively, on the martingale residuals and the contrast between the non‐parametric and model‐based estimators of the survival function. These tests are shown to be consistent against any departure from the model. The empirical behaviours of the tests are studied in simulations, and the tests are illustrated with some real data examples.     

A Flexible Approach to Time-varying Coefficients in the Cox Regression Setting

Research on methods for studying time-to-event data (survival analysis) has been extensive in recent years. The basic model in use today represents the hazard function for an individual through a proportional hazards model (Cox, 1972). Typically, it is assumed that a covariate's effect on the hazard function is constant throughout the course of the study. In this paper we propose a method to allow for possible deviations from the standard Cox model, by allowing the effect of a covariate to vary over time. This method is based on a dynamic linear model. We present our method in terms of a Bayesian hierarchical model. We fit the model to the data using Markov chain Monte Carlo methods. Finally, we illustrate the approach with several examples. This revised version was published online in July 2006 with corrections to the Cover Date.     

Estimation of treatment effects based on possibly misspecified Cox regression

In randomized clinical trials, a treatment effect on a time-to-event endpoint is often estimated by the Cox proportional hazards model. The maximum partial likelihood estimator does not make sense if the proportional hazard assumption is violated. Xu and O'Quigley (Biostatistics 1:423-439, 2000) proposed an estimating equation, which provides an interpretable estimator for the treatment effect under model misspecification. Namely it provides a consistent estimator for the log-hazard ratio among the treatment groups if the model is correctly specified, and it is interpreted as an average log-hazard ratio over time even if misspecified. However, the method requires the assumption that censoring is independent of treatment group, which is more restricted than that for the maximum partial likelihood estimator and is often violated in practice. In this paper, we propose an alternative estimating equation. Our method provides an estimator of the same property as that of Xu and O'Quigley under the usual assumption for the maximum partial likelihood estimation. We show that our estimator is consistent and asymptotically normal, and derive a consistent estimator of the asymptotic variance. If the proportional hazards assumption holds, the efficiency of the estimator can be improved by applying the covariate adjustment method based on the semiparametric theory proposed by Lu and Tsiatis (Biometrika 95:679-694, 2008).     

Generalized Proportional Hazards Model Based on Modified Partial Likelihood

The proportional hazards (Cox) model is generalized by assuming that at any moment the ratio of hazard rates is depending not only on values of covariates but also on resources used until this moment. Relations with generalized multiplicative, frailty and linear transformation models are considered. A modified partial likelihood function is proposed, and properties of the estimators are investigated.     

A Class of Parametric Dynamic Survival Models

A class of parametric dynamic survival models are explored in which only limited parametric assumptions are made, whilst avoiding the assumption of proportional hazards. Both the log-baseline hazard and covariate effects are modelled by piecewise constant and correlated processes. The method of estimation is to use Markov chain Monte Carlo simulations Gibbs sampling with a Metropolis–Hastings step. In addition to standard right censored data sets, extensions to accommodate interval censoring and random effects are included. The model is applied to two well known and illustrative data sets, and the dynamic variability of covariate effects investigated.     

Global Partial Likelihood for Nonparametric Proportional Hazards Models

As an alternative to the local partial likelihood method of Tibshirani and Hastie and Fan, Gijbels, and King, a global partial likelihood method is proposed to estimate the covariate effect in a nonparametric proportional hazards model, λ(t|x) = exp{ψ(x)}λ(0)(t). The estimator, ψ?(x), reduces to the Cox partial likelihood estimator if the covariate is discrete. The estimator is shown to be consistent and semiparametrically efficient for linear functionals of ψ(x). Moreover, Breslow-type estimation of the cumulative baseline hazard function, using the proposed estimator ψ?(x), is proved to be efficient. The asymptotic bias and variance are derived under regularity conditions. Computation of the estimator involves an iterative but simple algorithm. Extensive simulation studies provide evidence supporting the theory. The method is illustrated with the Stanford heart transplant data set. The proposed global approach is also extended to a partially linear proportional hazards model and found to provide efficient estimation of the slope parameter. This article has the supplementary materials online.     

Effect of censoring on adjusting for covariates in comparison of survival times

The increase in the variance of the estimate of treatment effect which results from omitting a dichotomous or continuous covariate is quantified as a function of censoring. The efficiency of not adjusting for a covariate is measured by the ratio of the variance obtained with and without adjustment for the covariate. The variance is derived using the Weibull proportional hazards model. Under random censoring, the efficiency of not adjusting for a continuous covariate is an increasing function of the percentage of censored observations.     

Proportional hazards estimate of the conditional survival function

We introduce a new estimator of the conditional survival function given some subset of the covariate values under a proportional hazards regression. The new estimate does not require estimating the base-line cumulative hazard function. An estimate of the variance is given and is easy to compute, involving only those quantities that are routinely calculated in a Cox model analysis. The asymptotic normality of the new estimate is shown by using a central limit theorem for Kaplan–Meier integrals. We indicate the straightforward extension of the estimation procedure under models with multiplicative relative risks, including non-proportional hazards, and to stratified and frailty models. The estimator is applied to a gastric cancer study where it is of interest to predict patients' survival based only on measurements obtained before surgery, the time at which the most important prognostic variable, stage, becomes known.