Establishing consistency across all regions in a multi-regional clinical trial

In recent years, global collaboration has become a conventional strategy for new drug development. To accelerate the development process and shorten approval time, the design of multi-regional clinical trials (MRCTs) incorporates subjects from many countries/regions around the world under the same protocol. After showing the overall efficacy of a drug in a global trial, one can also simultaneously evaluate the possibility of applying the overall trial results to all regions and subsequently support drug registration in each region. However, most of the recent approaches developed for the design and evaluation of MRCTs focus on establishing criteria to examine whether the overall results from the MRCT can be applied to a specific region. In this paper, we use the consistency criterion of Method 1 from the Japanese Ministry of Health, Labour and Welfare (MHLW) guidance to assess whether the overall results from the MRCT can be applied to all regions. Sample size determination for the MRCT is also provided to take all the consistency criteria from each individual region into account. Numerical examples are given to illustrate applications of the proposed approach.     

Regional efficacy evaluation in multi-regional clinical trials using a discounting factor weighted Z test

Multi-regional clinical trial (MRCT) is an efficient design to accelerate drug approval globally. Once the global efficacy of test drug is demonstrated, each local regulatory agency is required to prove effectiveness of test drug in their own population. Meanwhile, the ICH E5/E17 guideline recommends using data from other regions to help evaluate regional drug efficacy. However, one of the most challenges is how to manage to bridge data among multiple regions in an MRCT since various intrinsic and extrinsic factors exist among the participating regions. Furthermore, it is critical for a local agency to determine the proportion of information borrowing from other regions given the ethnic differences between target region and non-target regions. To address these issues, we propose a discounting factor weighted Z statistic to adaptively borrow information from non-target regions. In this weighted Z statistic, the weight is derived from a discounting factor in which the discounting factor denotes the proportion of information borrowing from non-target regions. We consider three ways to construct discounting factors based on the degree of congruency between target and non-target regions either using control group data, or treatment group data, or all data. We use the calibrated power prior to construct discounting factor based on scaled Kolmogorov–Smirnov statistic. Comprehensive simulation studies show that our method has desirable operating characteristics. Two examples are used to illustrate the applications of our proposed approach.     

Sample size allocation in multiregional equivalence studies

With the increasing globalization of drug development, the multiregional clinical trial (MRCT) has gained extensive use. The data from MRCTs could be accepted by regulatory authorities across regions and countries as the primary sources of evidence to support global marketing drug approval simultaneously. The MRCT can speed up patient enrollment and drug approval, and it makes the effective therapies available to patients all over the world simultaneously. However, there are many challenges both operationally and scientifically in conducting a drug development globally. One of many important questions to answer for the design of a multiregional study is how to partition sample size into each individual region. In this paper, two systematic approaches are proposed for the sample size allocation in a multiregional equivalence trial. A numerical evaluation and a biosimilar trial are used to illustrate the characteristics of the proposed approaches.     

Bayes shrinkage estimator for consistency assessment of treatment effects in multi-regional clinical trials

The primary objective of a multi-regional clinical trial is to investigate the overall efficacy of the drug across regions and evaluate the possibility of applying the overall trial result to some specific region. A challenge arises when there is not enough regional sample size. We focus on the problem of evaluating applicability of a drug to a specific region of interest under the criterion of preserving a certain proportion of the overall treatment effect in the region. We propose a variant of James-Stein shrinkage estimator in the empirical Bayes context for the region-specific treatment effect. The estimator has the features of accommodating the between-region variation and finiteness correction of bias. We also propose a truncated version of the proposed shrinkage estimator to further protect risk in the presence of extreme value of regional treatment effect. Based on the proposed estimator, we provide the consistency assessment criterion and sample size calculation for the region of interest. Simulations are conducted to demonstrate the performance of the proposed estimators in comparison with some existing methods. A hypothetical example is presented to illustrate the application of the proposed method.     

A Design For Survival Studies: A Multi-regional Trial With Unrecognized Heterogeneity

A bridging study defined by ICH E5 is usually conducted in the new region after the test product has been approved for commercial marketing in the original region due to its proven efficacy and safety. However, extensive duplication of clinical evaluation in the new region not only requires valuable development resources but also delay availability of the test product to the needed patients in the new regions. To shorten the drug lag or the time lag for approval, simultaneous drug development, submission, and approval in the world may be desirable. Recently, multi-regional trials have attracted much attention from sponsors as well as regulatory authorities. Current methods for sample determination are based on the assumption that true treatment effect is uniform across regions. However, unrecognized heterogeneity among patients as ethnic or genetic factor will effect patients’ survival. Using the simple log-rank test for analysis of treatment effect on survival in studies under heterogeneity may be severely underpowered. In this article, we address the issue that the treatment effects are different among regions to design a multi-regional trial. The optimal log-rank test is employed to deal with the heterogeneous effect size among regions. The test statistic for the overall treatment effect is used to determine the total sample size for a multi-regional trial and the consistent trend and the proposed criteria are used to rationalize partition sample size to each region.     

Sample Size Determination and Rational Partition for A Multi- Regional Trial for Survival (Time-To-Event) Data with Unrecognized Heterogeneity that Interacts with Treatment

To shorten the drug lag or the time lag for approval, simultaneous drug development, submission, and approval in the world may be desirable. Recently, multi-regional trials have attracted much attention from sponsors as well as regulatory authorities. Current methods for sample determination are based on the assumption that true treatment effect is uniform across regions. However, unrecognized heterogeneity among patients as ethnic or genetic factor will effect patients’ survival. In this article, we address the issue that the treatment effects with unrecognized heterogeneity that interacts with treatment are among regions to design a multi-regional trial. The log-rank test is employed to deal with the heterogeneous effect size among regions. The test statistic for the overall treatment effect is used to determine the total sample size for a multi-regional trial and the consistent trend is used to rationalize partition for sample size to each region.     

Methods for exploring treatment effect heterogeneity in subgroup analysis: an application to global clinical trials

Multi‐country randomised clinical trials (MRCTs) are common in the medical literature, and their interpretation has been the subject of extensive recent discussion. In many MRCTs, an evaluation of treatment effect homogeneity across countries or regions is conducted. Subgroup analysis principles require a significant test of interaction in order to claim heterogeneity of treatment effect across subgroups, such as countries in an MRCT. As clinical trials are typically underpowered for tests of interaction, overly optimistic expectations of treatment effect homogeneity can lead researchers, regulators and other stakeholders to over‐interpret apparent differences between subgroups even when heterogeneity tests are insignificant. In this paper, we consider some exploratory analysis tools to address this issue. We present three measures derived using the theory of order statistics, which can be used to understand the magnitude and the nature of the variation in treatment effects that can arise merely as an artefact of chance. These measures are not intended to replace a formal test of interaction but instead provide non‐inferential visual aids, which allow comparison of the observed and expected differences between regions or other subgroups and are a useful supplement to a formal test of interaction. We discuss how our methodology differs from recently published methods addressing the same issue. A case study of our approach is presented using data from the Study of Platelet Inhibition and Patient Outcomes (PLATO), which was a large cardiovascular MRCT that has been the subject of controversy in the literature. An R package is available that implements the proposed methods. Copyright © 2014 John Wiley & Sons, Ltd.     

Comparisons of allocating sample size rationally into individual regions under heterogeneous effect size in a multiregional trial by a fixed effect model and a random effect model

ABSTRACT

Recently, sponsors and regulatory authorities pay much attention on the multiregional trial because it can shorten the drug lag or the time lag for approval, simultaneous drug development, submission, and approval in the world. However, many studies have shown that genetic determinants may mediate variability among persons in response to a drug. Thus, some therapeutics benefit part of treated patients. It means that the assumption of homogeneous effect size is not suitable for multiregional trials. In this paper, we conduct the sample size determination of a multiregional clinical trial calculated by fixed effect and random effect under the assumption of heterogeneous effect size. The performances of fixed effect and random effect on allocating sample size on a specific region are compared by statistical criteria for consistency between the region of interest and overall results.     

A Statistical Issue About a Phase III Multi-regional Trial for the Survival Data under Accelerated Failure Time Model with Unrecognized Heterogeneity

For the time-to-event outcome, current methods for sample size determination are based on the proportional hazard model. However, if the proportionality assumption fails to capture the relationship between the hazard time and covariates, the proportional hazard model is not suitable to analyze survival data. The accelerated failure time model is an alternative method to deal with survival data. In this article, we address the issue that the relationship between the hazard time and the treatment effect is satisfied with the accelerated failure time model to design a multi-regional trial for a phase III clinical trial. The log-rank test is employed to deal with the heterogeneous effect size among regions. The test statistic for the overall treatment effect is used to determine the total sample size for a multi-regional trial and the consistent trend is used to rationalize partition sample size to each region.     

An Approach to Determine Sample Size and to Allocate Sample Size for a Specific Region in a Multiregional Trial for Survival (Time-to-Event) Data under Accelerated Failure Time Model

For the time-to-event outcome, current methods for sample determination are based on the proportional hazard model. However, if the proportionality assumption fails to capture the relationship between the hazard time and covariates, the proportional hazard model is not suitable to analyze survival data. The accelerated failure time (AFT) model is an alternative method to deal with survival data. In this paper, we address the issue that the relationship between the hazard time and the treatment effect is satisfied with the AFT model to design a multiregional trial. The log-rank test is employed to deal with the heterogeneous effect size among regions. The test statistic for the overall treatment effect is used to determine the total sample size for a multiregional trial, and the proposed criteria are used to rationalize partition sample size to each region.     

Optimal designs for the development of personalized treatment rules

We study the design of multi-armed parallel group clinical trials to estimate personalized treatment rules that identify the best treatment for a given patient with given covariates. Assuming that the outcomes in each treatment arm are given by a homoscedastic linear model, with possibly different variances between treatment arms, and that the trial subjects form a random sample from an unselected overall population, we optimize the (possibly randomized) treatment allocation allowing the allocation rates to depend on the covariates. We find that, for the case of two treatments, the approximately optimal allocation rule does not depend on the value of the covariates but only on the variances of the responses. In contrast, for the case of three treatments or more, the optimal treatment allocation does depend on the values of the covariates as well as the true regression coefficients. The methods are illustrated with a recently published dietary clinical trial.     

Estimates of subgroup treatment effects in overall nonsignificant trials: To what extent should we believe in them?

In drug development, it sometimes occurs that a new drug does not demonstrate effectiveness for the full study population but appears to be beneficial in a relevant subgroup. In case the subgroup of interest was not part of a confirmatory testing strategy, the inflation of the overall type I error is substantial and therefore such a subgroup analysis finding can only be seen as exploratory at best. To support such exploratory findings, an appropriate replication of the subgroup finding should be undertaken in a new trial. We should, however, be reasonably confident in the observed treatment effect size to be able to use this estimate in a replication trial in the subpopulation of interest. We were therefore interested in evaluating the bias of the estimate of the subgroup treatment effect, after selection based on significance for the subgroup in an overall “failed” trial. Different scenarios, involving continuous as well as dichotomous outcomes, were investigated via simulation studies. It is shown that the bias associated with subgroup findings in overall nonsignificant clinical trials is on average large and varies substantially across plausible scenarios. This renders the subgroup treatment estimate from the original trial of limited value to design the replication trial. An empirical Bayesian shrinkage method is suggested to minimize this overestimation. The proposed estimator appears to offer either a good or a conservative correction to the observed subgroup treatment effect hence provides a more reliable subgroup treatment effect estimate for adequate planning of future studies.     

Evaluate the relative efficiency of a targeted clinical trial design to an untargeted design under the issue of cost

In this article, we evaluate the relative cost of a targeted design to an untargeted design for a randomized clinical trial comparing a new treatment to a control. We observed that when the ratio of screen cost per person and drug cost per person is very small, say 0.008, the trial cost for conducting a targeted design might be fewer than that for conducting an untargeted design. When the difference between the treatment effect for the targeted patients and the treatment effect for the untargeted patients is increased, the savings in trial cost for the targeted design would be increased significantly. The greater sensitivity and specificity for the screen tool will lead to greater savings in trial cost for the targeted design. The relative cost of a targeted design to an untargeted design is associated with the treatment effect difference between targeted and untargeted patients, the proportion of targeted patients in the population, the screen tool performance, and the ratio of drug cost per person and screen cost per person.     

Approaches to sample size calculation for clinical trials in rare diseases

We discuss 3 alternative approaches to sample size calculation: traditional sample size calculation based on power to show a statistically significant effect, sample size calculation based on assurance, and sample size based on a decision‐theoretic approach. These approaches are compared head‐to‐head for clinical trial situations in rare diseases. Specifically, we consider 3 case studies of rare diseases (Lyell disease, adult‐onset Still disease, and cystic fibrosis) with the aim to plan the sample size for an upcoming clinical trial. We outline in detail the reasonable choice of parameters for these approaches for each of the 3 case studies and calculate sample sizes. We stress that the influence of the input parameters needs to be investigated in all approaches and recommend investigating different sample size approaches before deciding finally on the trial size. Highly influencing for the sample size are choice of treatment effect parameter in all approaches and the parameter for the additional cost of the new treatment in the decision‐theoretic approach. These should therefore be discussed extensively.     

Indirect comparisons in the comparative efficacy and non-inferiority settings

International Conference on Harmonization E10 concerns non-inferiority trials and the assessment of comparative efficacy, both of which often involve indirect comparisons. In the non-inferiority setting, there are clinical trial results directly comparing an experimental treatment with an active control, and clinical trial results directly comparing the active control with placebo, and there is an interest in the indirect comparison of the experimental treatment with placebo. In the comparative efficacy setting, there may be separate clinical trial results comparing each of two treatments with placebo, and there is interest in an indirect comparison of the treatments. First, we show that the sample size required for a trial intended to demonstrate superiority through an indirect comparison is always greater than the sample size required for a direct comparison. In addition, by introducing the concept of preservation of effect, we show that the hypothesis addressed in the two settings is identical. Our main result concerns the logical inconsistency between a reasonable criterion for preference of an experimental treatment to a standard treatment and existing regulatory guidance for approval of the experimental treatment on the basis of an indirect comparison. Specifically, the preferred treatment will not always meet the criterion for regulatory approval. This is due to the fact that the experimental treatment bears the burden of overcoming the uncertainty in the effect of the standard treatment. We consider an alternative approval criterion that avoids this logical inconsistency.     

The role of the minimum clinically important difference and its impact on designing a trial

The minimum clinically important difference (MCID) between treatments is recognized as a key concept in the design and interpretation of results from a clinical trial. Yet even assuming such a difference can be derived, it is not necessarily clear how it should be used. In this paper, we consider three possible roles for the MCID. They are: (1) using the MCID to determine the required sample size so that the trial has a pre-specified statistical power to conclude a significant treatment effect when the treatment effect is equal to the MCID; (2) requiring with high probability, the observed treatment effect in a trial, in addition to being statistically significant, to be at least as large as the MCID; (3) demonstrating via hypothesis testing that the effect of the new treatment is at least as large as the MCID. We will examine the implications of the three different possible roles of the MCID on sample size, expectations of a new treatment, and the chance for a successful trial. We also give our opinion on how the MCID should generally be used in the design and interpretation of results from a clinical trial.     

Point estimates and confidence regions for sequential trials involving selection

A number of authors have proposed clinical trial designs involving the comparison of several experimental treatments with a control treatment in two or more stages. At the end of the first stage, the most promising experimental treatment is selected, and all other experimental treatments are dropped from the trial. Provided it is good enough, the selected experimental treatment is then compared with the control treatment in one or more subsequent stages. The analysis of data from such a trial is problematic because of the treatment selection and the possibility of stopping at interim analyses. These aspects lead to bias in the maximum-likelihood estimate of the advantage of the selected experimental treatment over the control and to inaccurate coverage for the associated confidence interval. In this paper, we evaluate the bias of the maximum-likelihood estimate and propose a bias-adjusted estimate. We also propose an approach to the construction of a confidence region for the vector of advantages of the experimental treatments over the control based on an ordering of the sample space. These regions are shown to have accurate coverage, although they are also shown to be necessarily unbounded. Confidence intervals for the advantage of the selected treatment are obtained from the confidence regions and are shown to have more accurate coverage than the standard confidence interval based upon the maximum-likelihood estimate and its asymptotic standard error.     

On a multiple endpoints testing problem

In a clinical trial comparing drug with placebo, where there are multiple primary endpoints, we consider testing problems where an efficacious drug effect can be claimed only if statistical significance is demonstrated at the nominal level for all endpoints. Under the assumption that the data are multivariate normal, the multiple endpoint-testing problem is formulated. The usual testing procedure involves testing each endpoint separately at the same significance level using two-sample t-tests, and claiming drug efficacy only if each t-statistic is significant. In this paper we investigate properties of this procedure. We show that it is identical to both an intersection union test and the likelihood ratio test. A simple expression for the p-value is given. The level and power function are studied; it is shown that the test may be conservative and that it is biased. Computable bounds for the power function are established.     

Sensitivity analyses for the principal ignorability assumption using multiple imputation

In the context of clinical trials, there is interest in the treatment effect for subpopulations of patients defined by intercurrent events, namely disease-related events occurring after treatment initiation that affect either the interpretation or the existence of endpoints. With the principal stratum strategy, the ICH E9(R1) guideline introduces a formal framework in drug development for defining treatment effects in such subpopulations. Statistical estimation of the treatment effect can be performed based on the principal ignorability assumption using multiple imputation approaches. Principal ignorability is a conditional independence assumption that cannot be directly verified; therefore, it is crucial to evaluate the robustness of results to deviations from this assumption. As a sensitivity analysis, we propose a joint model that multiply imputes the principal stratum membership and the outcome variable while allowing different levels of violation of the principal ignorability assumption. We illustrate with a simulation study that the joint imputation model-based approaches are superior to naive subpopulation analyses. Motivated by an oncology clinical trial, we implement the sensitivity analysis on a time-to-event outcome to assess the treatment effect in the subpopulation of patients who discontinued due to adverse events using a synthetic dataset. Finally, we explore the potential usage and provide interpretation of such analyses in clinical settings, as well as possible extension of such models in more general cases.     

Applications of Bayesian analysis to proof‐of‐concept trial planning and decision making

Decision making is a critical component of a new drug development process. Based on results from an early clinical trial such as a proof of concept trial, the sponsor can decide whether to continue, stop, or defer the development of the drug. To simplify and harmonize the decision‐making process, decision criteria have been proposed in the literature. One of them is to exam the location of a confidence bar relative to the target value and lower reference value of the treatment effect. In this research, we modify an existing approach by moving some of the “stop” decision to “consider” decision so that the chance of directly terminating the development of a potentially valuable drug can be reduced. As Bayesian analysis has certain flexibilities and can borrow historical information through an inferential prior, we apply the Bayesian analysis to the trial planning and decision making. Via a design prior, we can also calculate the probabilities of various decision outcomes in relationship with the sample size and the other parameters to help the study design. An example and a series of computations are used to illustrate the applications, assess the operating characteristics, and compare the performances of different approaches.