Optimal partitioning for the proportional hazards model

This paper discusses methods for clustering a continuous covariate in a survival analysis model. The advantages of using a categorical covariate defined from discretizing a continuous covariate (via clustering) is (i) enhanced interpretability of the covariate''s impact on survival and (ii) relaxing model assumptions that are usually required for survival models, such as the proportional hazards model. Simulations and an example are provided to illustrate the methods.     

A nonparametric test for proving noninferiority in clinical trials with ordered categorical data

We consider the problem of proving noninferiority when the comparison is based on ordered categorical data. We apply a rank test based on the Wilcoxon–Mann–Whitney effect where the asymptotic variance is estimated consistently under the alternative and a small‐sample approximation is given. We give the associated 100(1?α)% confidence interval and propose a formula for sample size determination. Finally, we illustrate the procedure and possible choices of the noninferiority margin using data from a clinical trial. Copyright © 2003 John Wiley & Sons, Ltd.     

Sample size estimation for non-inferiority trials of time-to-event data

We consider the problem of sample size calculation for non-inferiority based on the hazard ratio in time-to-event trials where overall study duration is fixed and subject enrollment is staggered with variable follow-up. An adaptation of previously developed formulae for the superiority framework is presented that specifically allows for effect reversal under the non-inferiority setting, and its consequent effect on variance. Empirical performance is assessed through a small simulation study, and an example based on an ongoing trial is presented. The formulae are straightforward to program and may prove a useful tool in planning trials of this type.     

Design and analysis of a 3‐arm noninferiority trial with a prespecified margin for the hazard ratio

A 3‐arm trial design that includes an experimental treatment, an active reference treatment, and a placebo is useful for assessing the noninferiority of an experimental treatment. The inclusion of a placebo arm enables the assessment of assay sensitivity and internal validation, in addition to the testing of the noninferiority of the experimental treatment compared with the reference treatment. In 3‐arm noninferiority trials, various statistical test procedures have been considered to evaluate the following 3 hypotheses: (i) superiority of the experimental treatment over the placebo, (ii) superiority of the reference treatment over the placebo, and (iii) noninferiority of the experimental treatment compared with the reference treatment. However, hypothesis (ii) can be insufficient and may not accurately assess the assay sensitivity for the noninferiority of the experimental treatment compared with the reference treatment. Thus, demonstrating that the superiority of the reference treatment over the placebo is greater than the noninferiority margin (the nonsuperiority of the reference treatment compared with the placebo) can be necessary. Here, we propose log‐rank statistical procedures for evaluating data obtained from 3‐arm noninferiority trials to assess assay sensitivity with a prespecified margin Δ. In addition, we derive the approximate sample size and optimal allocation required to minimize the total sample size and that of the placebo treatment sample size, hierarchically.     

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.     

Delayed treatment effects,treatment switching and heterogeneous patient populations: How to design and analyze RCTs in oncology

In the analysis of survival times, the logrank test and the Cox model have been established as key tools, which do not require specific distributional assumptions. Under the assumption of proportional hazards, they are efficient and their results can be interpreted unambiguously. However, delayed treatment effects, disease progression, treatment switchers or the presence of subgroups with differential treatment effects may challenge the assumption of proportional hazards. In practice, weighted logrank tests emphasizing either early, intermediate or late event times via an appropriate weighting function may be used to accommodate for an expected pattern of non-proportionality. We model these sources of non-proportional hazards via a mixture of survival functions with piecewise constant hazard. The model is then applied to study the power of unweighted and weighted log-rank tests, as well as maximum tests allowing different time dependent weights. Simulation results suggest a robust performance of maximum tests across different scenarios, with little loss in power compared to the most powerful among the considered weighting schemes and huge power gain compared to unfavorable weights. The actual sources of non-proportional hazards are not obvious from resulting populationwise survival functions, highlighting the importance of detailed simulations in the planning phase of a trial when assuming non-proportional hazards.We provide the required tools in a software package, allowing to model data generating processes under complex non-proportional hazard scenarios, to simulate data from these models and to perform the weighted logrank tests.     

Model diagnostics for the proportional hazards model with length-biased data

Length-biased data are frequently encountered in prevalent cohort studies. Many statistical methods have been developed to estimate the covariate effects on the survival outcomes arising from such data while properly adjusting for length-biased sampling. Among them, regression methods based on the proportional hazards model have been widely adopted. However, little work has focused on checking the proportional hazards model assumptions with length-biased data, which is essential to ensure the validity of inference. In this article, we propose a statistical tool for testing the assumed functional form of covariates and the proportional hazards assumption graphically and analytically under the setting of length-biased sampling, through a general class of multiparameter stochastic processes. The finite sample performance is examined through simulation studies, and the proposed methods are illustrated with the data from a cohort study of dementia in Canada.

     

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.     

A Frailty Model in Crossover Studies with Time-to-Event Response Variable

In this article, we develop a model to study treatment, period, carryover, and other applicable effects in a crossover design with a time-to-event response variable. Because time-to-event outcomes on different treatment regimens within the crossover design are correlated for an individual, we adopt a proportional hazards frailty model. If the frailty is assumed to have a gamma distribution, and the hazard rates are piecewise constant, then the likelihood function can be determined via closed-form expressions. We illustrate the methodology via an application to a data set from an asthma clinical trial and run simulations that investigate sensitivity of the model to data generated from different distributions.     

Testing for Covariate Effect in the Cox Proportional Hazards Regression Model

This article presents methods for testing covariate effect in the Cox proportional hazards model based on Kullback–Leibler divergence and Renyi's information measure. Renyi's measure is referred to as the information divergence of order γ (γ ≠ 1) between two distributions. In the limiting case γ → 1, Renyi's measure becomes Kullback–Leibler divergence. In our case, the distributions correspond to the baseline and one possibly due to a covariate effect. Our proposed statistics are simple transformations of the parameter vector in the Cox proportional hazards model, and are compared with the Wald, likelihood ratio and score tests that are widely used in practice. Finally, the methods are illustrated using two real-life data sets.     

A Corrected Pseudo-score Approach for Additive Hazards Model with Longitudinal Covariates Measured with Error

In medical studies, it is often of interest to characterize the relationship between a time-to-event and covariates, not only time-independent but also time-dependent. Time-dependent covariates are generally measured intermittently and with error. Recent interests focus on the proportional hazards framework, with longitudinal data jointly modeled through a mixed effects model. However, approaches under this framework depend on the normality assumption of the error, and might encounter intractable numerical difficulties in practice. This motivates us to consider an alternative framework, that is, the additive hazards model, about which little research has been done when time-dependent covariates are measured with error. We propose a simple corrected pseudo-score approach for the regression parameters with no assumptions on the distribution of the random effects and the error beyond those for the variance structure of the latter. The estimator has an explicit form and is shown to be consistent and asymptotically normal. We illustrate the method via simulations and by application to data from an HIV clinical trial.     

An evidential approach to non-inferiority clinical trials

We present likelihood methods for defining the non-inferiority margin and measuring the strength of evidence in non-inferiority trials using the 'fixed-margin' framework. Likelihood methods are used to (1) evaluate and combine the evidence from historical trials to define the non-inferiority margin, (2) assess and report the smallest non-inferiority margin supported by the data, and (3) assess potential violations of the constancy assumption. Data from six aspirin-controlled trials for acute coronary syndrome and data from an active-controlled trial for acute coronary syndrome, Organisation to Assess Strategies for Ischemic Syndromes (OASIS-2) trial, are used for illustration. The likelihood framework offers important theoretical and practical advantages when measuring the strength of evidence in non-inferiority trials. Besides eliminating the influence of sample spaces and prior probabilities on the 'strength of evidence in the data', the likelihood approach maintains good frequentist properties. Violations of the constancy assumption can be assessed in the likelihood framework when it is appropriate to assume a unifying regression model for trial data and a constant control effect including a control rate parameter and a placebo rate parameter across historical placebo controlled trials and the non-inferiority trial. In situations where the statistical non-inferiority margin is data driven, lower likelihood support interval limits provide plausibly conservative candidate margins.     

Applications of asymptotic confidence intervals with continuity corrections for asymmetric comparisons in noninferiority trials

A large‐sample problem of illustrating noninferiority of an experimental treatment over a referent treatment for binary outcomes is considered. The methods of illustrating noninferiority involve constructing the lower two‐sided confidence bound for the difference between binomial proportions corresponding to the experimental and referent treatments and comparing it with the negative value of the noninferiority margin. The three considered methods, Anbar, Falk–Koch, and Reduced Falk–Koch, handle the comparison in an asymmetric way, that is, only the referent proportion out of the two, experimental and referent, is directly involved in the expression for the variance of the difference between two sample proportions. Five continuity corrections (including zero) are considered with respect to each approach. The key properties of the corresponding methods are evaluated via simulations. First, the uncorrected two‐sided confidence intervals can, potentially, have smaller coverage probability than the nominal level even for moderately large sample sizes, for example, 150 per group. Next, the 15 testing methods are discussed in terms of their Type I error rate and power. In the settings with a relatively small referent proportion (about 0.4 or smaller), the Anbar approach with Yates’ continuity correction is recommended for balanced designs and the Falk–Koch method with Yates’ correction is recommended for unbalanced designs. For relatively moderate (about 0.6) and large (about 0.8 or greater) referent proportion, the uncorrected Reduced Falk–Koch method is recommended, although in this case, all methods tend to be over‐conservative. These results are expected to be used in the design stage of a noninferiority study when asymmetric comparisons are envisioned. Copyright © 2013 John Wiley & Sons, Ltd.     

Sample size determination for clustered right-censored data using copula models

Determination of an adequate sample size is critical to the design of research ventures. For clustered right-censored data, Manatunga and Chen [Sample size estimation for survival outcomes in cluster-randomized studies with small cluster sizes. Biometrics. 2000;56(2):616–621] proposed a sample size calculation based on considering the bivariate marginal distribution as Clayton copula model. In addition to the Clayton copula, other important family of copulas, such as Gumbel and Frank copulas are also well established in multivariate survival analysis. However, sample size calculation based on these assumptions has not been fully investigated yet. To broaden the scope of Manatunga and Chen [Sample size estimation for survival outcomes in cluster-randomized studies with small cluster sizes. Biometrics. 2000;56(2):616–621]'s research and achieve a more flexible sample size calculation for clustered right-censored data, we extended the work by assuming the marginal distribution as bivariate Gumbel and Frank copulas. We evaluate the performance of the proposed method and investigate the impacts of the accrual times, follow-up times and the within-clustered correlation effect of the study. The proposed method is applied to two real-world studies, and the R code is made available to users.     

Analysis of exacerbation rates in asthma and chronic obstructive pulmonary disease: example from the TRISTAN study

Recurrent events in clinical trials have typically been analysed using either a multiple time-to-event method or a direct approach based on the distribution of the number of events. An area of application for these methods is exacerbation data from respiratory clinical trials. The different approaches to the analysis and the issues involved are illustrated for a large trial (n = 1465) in chronic obstructive pulmonary disease (COPD). For exacerbation rates, clinical interest centres on a direct comparison of rates for each treatment which favours the distribution-based analysis, rather than a time-to-event approach. Poisson regression has often been employed and has recently been recommended as the appropriate method of analysis for COPD exacerbations but the key assumptions often appear unreasonable for this analysis. By contrast use of a negative binomial model which corresponds to assuming a separate Poisson parameter for each subject offers a more appealing approach. Non-parametric methods avoid some of the assumptions required by these models, but do not provide appropriate estimates of treatment effects because of the discrete and bounded nature of the data.     

Frailty modeling for clustered survival data: an application to birth interval in Bangladesh

The present work demonstrates an application of random effects model for analyzing birth intervals that are clustered into geographical regions. Observations from the same cluster are assumed to be correlated because usually they share certain unobserved characteristics between them. Ignoring the correlations among the observations may lead to incorrect standard errors of the estimates of parameters of interest. Beside making the comparisons between Cox's proportional hazards model and random effects model for analyzing geographically clustered time-to-event data, important demographic and socioeconomic factors that may affect the length of birth intervals of Bangladeshi women are also reported in this paper.     

Progressively Type-I interval censored competing risks data for the proportional hazards family

In this article, we consider some problems of estimation and prediction when progressive Type-I interval censored competing risks data are from the proportional hazards family. The maximum likelihood estimators of the unknown parameters are obtained. Based on gamma priors, the Lindely's approximation and importance sampling methods are applied to obtain Bayesian estimators under squared error and linear–exponential loss functions. Several classical and Bayesian point predictors of censored units are provided. Also, based on given producer's and consumer's risks accepting sampling plans are considered. Finally, the simulation study is given by Monte Carlo simulations to evaluate the performances of the different methods.     

Sample size calculation for a proportional hazards mixture cure model with nonbinary covariates

Sample size calculation is a critical issue in clinical trials because a small sample size leads to a biased inference and a large sample size increases the cost. With the development of advanced medical technology, some patients can be cured of certain chronic diseases, and the proportional hazards mixture cure model has been developed to handle survival data with potential cure information. Given the needs of survival trials with potential cure proportions, a corresponding sample size formula based on the log-rank test statistic for binary covariates has been proposed by Wang et al. [25]. However, a sample size formula based on continuous variables has not been developed. Herein, we presented sample size and power calculations for the mixture cure model with continuous variables based on the log-rank method and further modified it by Ewell's method. The proposed approaches were evaluated using simulation studies for synthetic data from exponential and Weibull distributions. A program for calculating necessary sample size for continuous covariates in a mixture cure model was implemented in R.     

Calculating power for the comparison of dependent κ-coefficients

Summary. In the psychosocial and medical sciences, some studies are designed to assess the agreement between different raters and/or different instruments. Often the same sample will be used to compare the agreement between two or more assessment methods for simplicity and to take advantage of the positive correlation of the ratings. Although sample size calculations have become an important element in the design of research projects, such methods for agreement studies are scarce. We adapt the generalized estimating equations approach for modelling dependent κ -statistics to estimate the sample size that is required for dependent agreement studies. We calculate the power based on a Wald test for the equality of two dependent κ -statistics. The Wald test statistic has a non-central χ ²-distribution with non-centrality parameter that can be estimated with minimal assumptions. The method proposed is useful for agreement studies with two raters and two instruments, and is easily extendable to multiple raters and multiple instruments. Furthermore, the method proposed allows for rater bias. Power calculations for binary ratings under various scenarios are presented. Analyses of two biomedical studies are used for illustration.     

How to avoid concerns with the interpretation of two primary endpoints if significant superiority in one is sufficient for formal proof of efficacy

Formal proof of efficacy of a drug requires that in a prospective experiment, superiority over placebo, or either superiority or at least non-inferiority to an established standard, is demonstrated. Traditionally one primary endpoint is specified, but various diseases exist where treatment success needs to be based on the assessment of two primary endpoints. With co-primary endpoints, both need to be “significant” as a prerequisite to claim study success. Here, no adjustment of the study-wise type-1-error is needed, but sample size is often increased to maintain the pre-defined power. Studies that use an at-least-one concept have been proposed where study success is claimed if superiority for at least one of the endpoints is demonstrated. This is sometimes also called the dual primary endpoint concept, and an appropriate adjustment of the study-wise type-1-error is required. This concept is not covered in the European Guideline on multiplicity because study success can be claimed if one endpoint shows significant superiority, despite a possible deterioration in the other. In line with Röhmel's strategy, we discuss an alternative approach including non-inferiority hypotheses testing that avoids obvious contradictions to proper decision-making. This approach leads back to the co-primary endpoint assessment, and has the advantage that minimum requirements for endpoints can be modeled flexibly for several practical needs. Our simulations show that, if planning assumptions are correct, the proposed additional requirements improve interpretation with only a limited impact on power, that is, on sample size.