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Floden L, DeRosa M, Roydhouse J, Beaumont JL, Hudgens S. [Special issue PRO] A demonstration of estimands and sensitivity analyses for time-to-deterioration of patient reported outcomes. J Biopharm Stat 2024:1-15. [PMID: 38686622 DOI: 10.1080/10543406.2024.2341649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2023] [Accepted: 04/05/2024] [Indexed: 05/02/2024]
Abstract
In oncology trials, health-related quality of life (HRQoL), specifically patient-reported symptom burden and functional status, can support the interpretation of survival endpoints, such as progression-free survival. However, applying time-to-event endpoints to patient-reported outcomes (PRO) data is challenging. For example, in time-to-deterioration analyses clinical events such as disease progression are common in many settings and are often handled through censoring the patient at the time of occurrence; however, disease progression and HRQoL are often related leading to informative censoring. Special consideration to the definition of events and intercurrent events (ICEs) is necessary. In this work, we demonstrate time-to-deterioration of PRO estimands and sensitivity analyses to answer research questions using composite, hypothetical, and treatment policy strategies applied to a single endpoint of disease-related symptoms. Multiple imputation methods under both the missing-at-random and missing-not-at-random assumptions are used as sensitivity analyses of primary estimands. Hazard ratios ranged from 0.52 to 0.66 over all the estimands and sensitivity analyses modeling a robust treatment effect favoring the treatment in time to disease symptom deterioration or death. Differences in the estimands include how people who experience disease progression or discontinue the randomized treatment due to AEs are accounted for in the analysis. We use the estimand framework to define interpretable and principled approaches for different time-to-deterioration research questions and provide practical recommendations. Reporting the proportions of patient events and patient censoring by reason helps understand the mechanisms that drive the results, allowing for optimal interpretation.
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Affiliation(s)
- Lysbeth Floden
- Quantitative Sciences, Clinical Outcomes Solutions LLC, Tucson, USA
| | - Michael DeRosa
- Quantitative Sciences, Clinical Outcomes Solutions LLC, Tucson, USA
| | - Jessica Roydhouse
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia
| | | | - Stacie Hudgens
- Quantitative Sciences, Clinical Outcomes Solutions LLC, Tucson, USA
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Mitroiu M, Teerenstra S, Oude Rengerink K, Pétavy F, Roes KCB. Estimation of treatment effects in short-term depression studies. An evaluation based on the ICH E9(R1) estimands framework. Pharm Stat 2022; 21:1037-1057. [PMID: 35678545 PMCID: PMC9543408 DOI: 10.1002/pst.2214] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2021] [Revised: 02/18/2022] [Accepted: 04/11/2022] [Indexed: 11/25/2022]
Abstract
Estimands aim to incorporate intercurrent events in design, data collection and estimation of treatment effects in clinical trials. Our aim was to understand what estimands may correspond to efficacy analyses commonly employed in clinical trials conducted before publication of ICH E9(R1). We re-analysed six clinical trials evaluating a new anti-depression treatment. We selected the following analysis methods-ANCOVA on complete cases, following last observation carried forward (LOCF) imputation and following multiple imputation; mixed-models for repeated measurements without imputation (MMRM), MMRM following LOCF imputation and following jump-to-reference imputation; and pattern-mixture mixed models. We included a principal stratum analysis based on the predicted subset of the study population who would not discontinue due to adverse events or lack of efficacy. We translated each analysis into the implicitly targeted estimand, and formulated corresponding clinical questions. We could map six estimands to analysis methods. The same analysis method could be mapped to more than one estimand. The major difference between estimands was the strategy for intercurrent events, with other attributes mostly the same across mapped estimands. The quantitative differences in MADRS10 population-level summaries between the estimands were 4-8 points. Not all six estimands had a clinically meaningful interpretation. Only a few analyses would target the same estimand, hence only few could be used as sensitivity analyses. The fact that an analysis could estimate different estimands emphasises the importance of prospectively defining the estimands targeting the primary objective of a trial. The fact that an estimand can be targeted by different analyses emphasises the importance of prespecifying precisely the estimator for the targeted estimand.
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Affiliation(s)
- Marian Mitroiu
- Methodology Working GroupCollege ter Beoordeling van Geneesmiddelen ‐ Medicines Evaluation BoardUtrechtThe Netherlands
- Clinical Trial Methodology Department, Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, Biostatistics and Research SupportUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Steven Teerenstra
- Methodology Working GroupCollege ter Beoordeling van Geneesmiddelen ‐ Medicines Evaluation BoardUtrechtThe Netherlands
- Department for Health Evidence, Section BiostatisticsRadboud University Medical CenterNijmegenThe Netherlands
| | - Katrien Oude Rengerink
- Methodology Working GroupCollege ter Beoordeling van Geneesmiddelen ‐ Medicines Evaluation BoardUtrechtThe Netherlands
- Clinical Trial Methodology Department, Biostatistics and Research Support, Julius Center for Health Sciences and Primary Care, Biostatistics and Research SupportUniversity Medical Center Utrecht, Utrecht UniversityUtrechtThe Netherlands
| | - Frank Pétavy
- Data Analytics and Methods TaskforceEuropean Medicines AgencyAmsterdamThe Netherlands
| | - Kit C. B. Roes
- Methodology Working GroupCollege ter Beoordeling van Geneesmiddelen ‐ Medicines Evaluation BoardUtrechtThe Netherlands
- Department for Health Evidence, Section BiostatisticsRadboud University Medical CenterNijmegenThe Netherlands
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Schmidli H, Roger JH, Akacha M. Estimands for Recurrent Event Endpoints in the Presence of a Terminal Event. Stat Biopharm Res 2021. [DOI: 10.1080/19466315.2021.1895883] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Affiliation(s)
| | - James H. Roger
- Medical Statistics Department, London School of Hygiene & Tropical Medicine, London, UK
| | - Mouna Akacha
- Statistical Methodology, Novartis, Basel, Switzerland, on behalf of the Recurrent Event Qualification Opinion Consortium
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Roblin X, Williet N, Boschetti G, Phelip JM, Del Tedesco E, Berger AE, Vedrines P, Duru G, Peyrin-Biroulet L, Nancey S, Flourie B, Paul S. Addition of azathioprine to the switch of anti-TNF in patients with IBD in clinical relapse with undetectable anti-TNF trough levels and antidrug antibodies: a prospective randomised trial. Gut 2020; 69:1206-1212. [PMID: 31980448 DOI: 10.1136/gutjnl-2019-319758] [Citation(s) in RCA: 83] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2019] [Revised: 01/10/2020] [Accepted: 01/13/2020] [Indexed: 12/12/2022]
Abstract
OBJECTIVES In patients with IBD experiencing an immune-mediated loss of response (LOR) to antitumour necrosis factor (anti-TNF), algorithms recommend a switch of anti-TNF without immunosuppressive drug. The aim of our study was to compare in these patients two strategies: either switch to a second anti-TNF alone or with addition of azathioprine (AZA). After randomisation outcomes (time to clinical and pharmacokinetic failure) were compared between the two groups during a 2-year follow-up period. DESIGN Consecutive IBD patients in immune-mediated LOR to a first optimised anti-TNF given in monotherapy were randomised to receive either AZA or nothing with induction by a second anti-TNF in both arms. Clinical failure was defined for Crohn's disease (CD) as a Harvey-Bradshaw index ≥5 associated with a faecal calprotectin level >250 µg/g stool and for UC as a Mayo score >5 with endoscopic subscore >1 or as the occurrence of adverse events requiring to stop treatment. Unfavourable pharmacokinetics of the second anti-TNF were defined by the appearance of undetectable trough levels of anti-TNF with high antibodies (drug-sensitive assay) or by that of antibodies (drug-tolerant assay). RESULTS Ninety patients (48 CDs) were included, and 45 of them received AZA after randomisation. The second anti-TNF was adalimumab or infliximab in 40 and 50 patients, respectively. Rates of clinical failure and occurrence of unfavourable pharmacokinetics were higher in monotherapy compared with combination therapy (p<0.001; median time of clinical failure since randomisation 18 vs >24 months). At 24 months, survival rates without clinical failure and without appearance of unfavourable pharmacokinetics were respectively 22 versus 77% and 22% versus 78% (p<0.001 for both) in monotherapy versus combination therapy. Only the use of combination therapy was associated with favourable outcomes after anti-TNF switch. CONCLUSION In case of immune-mediated LOR to a first anti-TNF, AZA should be associated with the second anti-TNF. TRIAL REGISTRATION NUMBER 03580876.
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Affiliation(s)
- Xavier Roblin
- Department of Gastroenterology, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Nicolas Williet
- Department of Gastroenterology, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Gilles Boschetti
- Department of Gastroenterology, Hospital Lyon-South, Pierre-Benite, France
| | - Jean-Marc Phelip
- Department of Gastroenterology, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Emilie Del Tedesco
- Department of Gastroenterology, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Anne-Emmanuelle Berger
- Department of Immunology, CIC 1408, GIMAP, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
| | - Philippe Vedrines
- Gastro-enterology Department, Centre Hospitalier du Forez à Montbrison Instituts de Formation, Montbrison, Auvergne-Rhône-Alpes, France
| | - Gerard Duru
- Department of Statistics, UCBL, Villeurbanne, Auvergne-Rhône-Alpes, France
| | - Laurent Peyrin-Biroulet
- Department of gastroenterology, University Hospital Centre Nancy, Nancy, Lorraine, France.,INSERM U954, Nancy 1 University, Nancy, Lorraine, France
| | - Stéphane Nancey
- Department of Gastroenterology, Hospital Lyon-South, Pierre-Benite, France
| | - Bernard Flourie
- Department of Gastroenterology, Hospital Lyon-South, Pierre-Benite, France
| | - Stephane Paul
- Department of Immunology, CIC 1408, GIMAP, CHU Saint-Étienne, Saint-Etienne, Rhône-Alpes, France
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Ring A, Wolfsegger MJ. The potential of the estimands framework for clinical pharmacology trials: Some discussion points. Br J Clin Pharmacol 2020; 86:1240-1247. [PMID: 32030776 DOI: 10.1111/bcp.14233] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2019] [Revised: 01/18/2020] [Accepted: 01/28/2020] [Indexed: 02/02/2023] Open
Abstract
The recently finalised and published guideline ICH E9 (R1) introduced a new framework for the statistical analysis of clinical trials, namely that of "estimands". While the framework was originally developed for the analysis of late-phase trials, it could also provide a rigorous basis for the analysis of clinical pharmacology trials. We illustrate potential applications on two examples: a multiple dose pharmacology trial and the interpretation of confirmatory bioequivalence (BE) trials according to the current FDA and EMA BE guidelines.
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Affiliation(s)
- Arne Ring
- University of the Free State, Bloemfontein, South Africa.,medac GmbH, Wedel, Germany
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