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Design and analysis of clinical trials

Design and analysis of clinical trials. MULTIPLE COMPARISONS. Contents. Error Rates Methods for Constructing MTPs Union-Intersection (At Least One) Method Intersection-Union (All or None) Method Closure Method Common p-Value Based MTPs Holm’s Procedure Simes ’ Test

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Design and analysis of clinical trials

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  1. Design and analysis of clinicaltrials • MULTIPLE COMPARISONS

  2. Contents • Error Rates • Methods for ConstructingMTPs • Union-Intersection (At Least One) Method • Intersection-Union (All or None) Method • ClosureMethod • Commonp-ValueBasedMTPs • Holm’sProcedure • Simes’ Test • Hochberg’sProcedure • MTPs for a priori OrderedHypotheses • FixedSequenceProcedure • Fallback Procedure • Examples Set area descriptor | Sub level 1

  3. What is the issue? When performing MANY independent tests, we shall expect to have at least one significant result even though no difference exists. Probability of at leastonefalsesignificantresult • The multiplicity problem Number of tests Probability 1 0.05 2 0.0975 5 0.226 10 0.401 50 0.923 • Doing a lot of tests will give us significant results just by chance. • We want to find methods to control this risk (error rate). • The same problem arises when considering many confidence intervals simultaneously. P(at least one false positive result) = 1 - P(zero false positive results) = 1 – (1 - .05) ^ k

  4. Sources of multiplicity in clinicaltrials 8 Set area descriptor | Sub level 1

  5. Regulatory requirements EMEA/CPMP’s (2002) Points to Consider on MultiplicityIssues …: (from Section 2.5) As a general rule it can be stated that control of the family-wisetype-Ierror in the strong sense (i.e. application of closed test procedures) is a minimal prerequisitefor confirmatoryclaims. (from Section 7) It is therefore necessary that the statistical procedures planned to deal with, or to avoid, multiplicity are fully detailed in the study protocol or in the statistical analysis plan to allow an assessment of their suitability and appropriateness. Additional claims on statistical significant and clinically relevant findings based on secondary variables or on subgroups are possible only after the primary objective of the clinical trial has been achieved, and if the respective questions were pre-specified, and were part of an appropriately planned statistical analysis strategy

  6. General rulesA. Multiple treatments • Arrange the treatment comparisons in order of importance • Decide which comparisons should belong to the confirmatory analysis • Decide a way to control the error of false significances for these comparisons

  7. General rulesB. Multiple variables • Find out which variables are needed to answer the primary objective of the study • Look for possibilities to combine the variables, e.g. composite endpoints, global measures (QoL, AUC etc.) • Decide a way to control the error of false significances for these variables

  8. General rulesC. Multiple time points • Find out which time points are the most relevant for the treatment comparison • If no single time point is most important, look for possibilities to combine the time points, e.g. average over time (AUC etc.) • Decide a way to control the error of false significances if more than one important time point

  9. General rulesD. Interim analyses • Decide if the study should stop for safety and/or efficacy reasons • Decide the number of interim analyses • To control the error of a false significance (stopping the study), decide how to spend the total significance level on the interim and final analysis

  10. General rulesE. Subgroup analyses • Subgroup analyses are usually not part of a confirmatory analysis • Restrict the number of subgroup analyses • Use only subgroups of sufficient size • All post-hoc subgroup analyses are considered exploratory

  11. What’s multiplicity got to do with me? • “I (am a Bayesian so I) do not agree with the principles behind adjustment” • OK, but regulatory authorities will (may) take a different view • “I work in oncology where we generally use all patients, have 1 treatment comparison, 1 primary endpoint (Time to event) and a small number of secondary endpoints” • Still multiplicity issues around secondary endpoints • Not always this simple: • 2 populations e.g. all, biomarker positive group • More than 1 treatment comparison eg experimental v control, experimental + control vs. control

  12. What’s multiplicity got to do with me? • “I work in early phase trials” • Phase II used for internal decision making so we do not have to take account of the multiplicity (trials would become too big if we did) • Agree, but issues of multiplicity still apply • AstraZeneca takes forward any increase in the risk of a false positive finding and as long as this is understood it may be acceptable

  13. Methodsbased on p-values Set area descriptor | Sub level 1

  14. Bonferroni • N different null hypotheses H1, … HN • Calculate corresponding p-values p1, … pN • Reject Hk if and only if pk < a/N Variation: The limits may be unequal as long as they sum up to a Conservative

  15. Bonferroni’s inequality • P(Ai) = P(reject H0iwhen it is true ) Reject at least one hypthesis falsely

  16. Example of Bonferroni correction • Suppose we have N = 3 t-tests. • Assume target alpha(T)= 0.05. • Bonferroni corrected p-value is alpha(T)/N = 0.05/3 = 0.0167 • Unadjusted p-values are • p1 = 0.001; p2 = 0.013; p3 = 0.074 • p1 = 0.001 < 0.0167, so reject H01 • p2 = 0.013 < 0.0167, so reject H02 • p3 = 0.074 > 0.0167, so do not reject H03

  17. Holm Set area descriptor | Sub level 1

  18. Holm • N different null hypotheses H01, … H0N • Calculate corresponding p-values p1, … pN • Order the p-values from the smallest to the largest, p(1) < ….<p(N) • Start with the smallest p-value and reject H(j) as long as p(j) < a/(N-j+1)

  19. Example of Holm’s test •  Suppose we have N = 3 t-tests. • Assume target alpha(T)= 0.05.  • Unadjusted p-values are • p1 = 0.001; p2 = 0.013; p3 = 0.074 • For the jth test, calculate a(j) = a(T)/(N – j +1) • For test j = 1, a (j) = a(T)/(N – j +1)= 0.05/(3 – 1 + 1) = 0.05 / 3= 0.0167

  20. For test j=1, the observed p1 = 0.001 is less than alpha(j) = 0.0167, so we reject the null hypothesis. • For test j = 2, • a(j) = a (T)/(N – j +1) • = 0.05/(3 – 2 + 1) • = 0.05 / 2 • = 0.025 • For test j=2, the observed p2 = 0.013 is less than a (j) = 0.025, so we reject the null hypothesis. • For test j = 3, • a(j) = a (T)/(N – j +1)= 0.05/(3 – 3 + 1) = 0.05 • For test j=3, the observed p2 = 0.074 is greater than a (j) = 0.05, so we do not reject the null hypothesis.

  21. Simes Set area descriptor | Sub level 1

  22. Hochberg Set area descriptor | Sub level 1

  23. Hochberg • N different null hypotheses H1, … HN • Calculate corresponding p-values p1, … pN • Order the p-values from the smallest to the largest, p(1) < ….<p(N) • Start with the largest p-value. If p(N) < a stop and declare all comparisons significant at level a (i.e. reject H(1) … H(N) at level a). Otherwise accept H(N) and go to the next step • if p(N-1) < a/2 stop and declare H(1) … H(N-1) significant. Otherwise accept H(N-1) and go to the next step • …. • If p(N-k+1) < a/(N-k+1) stop and declare H(1) … H(N-k+1) significant. Otherwise accept H(N-k+1) and go to the next step

  24. Example • Assume we performed N=5 tests of hypothesis simultaneously and want the result to be at the level 0.05. The p-values obtained were

  25. Bonferroni: 0.05/5=0.01. Since only p(1) is less than 0.01 we reject H(1) but accept the remaining hypotheses. • Holm: p(1), p(2) and p(3) are less than 0.05/5, 0.05/4 and 0.05/3 respectively so we reject the corresponding hypotheses H(1), H(2) and H(3). But p(4) = 0.134 > 0.05/2=0.025 so we stop and accept H(4) and H(5). • Hochberg: • 0.512 is not less than 0.05 so we accept H(5) • 0.134 is not less than 0.025 so we accept H(4) • 0.012 is less than 0.0153 so we reject H(1),H(2) and H(3)

  26. Family-wiseerror rates Set area descriptor | Sub level 1

  27. Example 1 Set area descriptor | Sub level 1

  28. Example 2 Set area descriptor | Sub level 1

  29. Methods for constructing multiple testing procedures Set area descriptor | Sub level 1

  30. Set area descriptor | Sub level 1

  31. Fixedsequence Set area descriptor | Sub level 1

  32. Fallback Set area descriptor | Sub level 1

  33. Summary Set area descriptor | Sub level 1

  34. Example 1 Set area descriptor | Sub level 1

  35. Set area descriptor | Sub level 1

  36. Example 2 Set area descriptor | Sub level 1

  37. Example. Two tests. • In a heart failurestudy, two tests were to be performed in a confirmatoryanalysis. One for testing a treatmenteffect on death and one to test symptomatic relief using a questionnaire (Quest).

  38. Example (cont.): • Bonferroni: Set 0.025 for death and 0.025 for Quest • Holm. Calculate the twop-values. If the smallest < 0.025 concludeeffect from that test. If the largestp-value < 0.05, concludeeffect from that test. • Hochberg. Calculate the twop-values. If the largest < 0.05 concludeeffect for both variables. If not and the smallest < 0.025, concludeeffect from that test.

  39. Example (cont.): • Closed test procedure. Chooseone of the variables to test first (must be pre-specified). Calculate the twop-values. If the p-value for the first variable is < 0.05, concludesignificance and test the second variable. If this p-value is also < 0.05, thenconcludesignificancealso for this variable. If the first p-value > 0.05 thennone of the variables are significant.

  40. Drug project example: Crestor (rosuvastatin) Multiplicity issue • Four drugs with multiple doses. The study was an open-label study that was planned to be post-NDA. • STELLAR was a 15-arm parallel group study comparing doses of rosuvastatin to doses of other statins: rosuva 10, 20, 40, 80 mg versus atorva 10, 20, 40, 80 mg versus prava 10, 20 40 mg versus simva 10, 20, 40, 80 mg. The primary variable was percent change from baseline in LDL-C.

  41. A commercial request was to compare rosuvastatin to other statins dose-to-dose. • To address this objective, 25 pairwise comparisons of interest were specified. • A Bonferroni correction was used to account for multiple comparisons. • The sample size was estimated considering the Bonferroni correction. It was a large study, with about n=150 per arm. • Choice of the conservative Bonferroni correction was influenced by the fact that a competitor received a warning letter from the FDA for dose-to-dose promotion from a study that was not designed to do dose-to-dose comparisons.

  42. There was no discussion with the FDA about correction for multiplicity in STELLAR. Results are considered robust, and they appear in the Crestor label. References •  Jones PH et al. Comparison of the efficacy and safety of rosuvastatin versus atorvastatin, simvastatin, and pravastatin across doses (STELLAR trial). Am J Cardiol 2003;92:152-160. • McKenney JM et al. Comparison of the efficacy of rosuvastatin versus atorvastatin, simvastatin, and pravastatin in achieving lipid goals: results from the STELLAR trial. Current Medical Research and Opinion 2003;19(8):689-698.

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