Logrank, play the winner, power and ethics

Compound optimal allocations for survival clinical trials

The aim of the present paper is to provide optimal allocations for comparative clinical trials with survival outcomes. The suggested targets are derived adopting a compound optimization strategy based on a subjective weighting of the relative importance of inferential demands and ethical concerns. The ensuing compound optimal targets are continuous functions of the treatment effects, so we provide the conditions under which they can be approached by standard response-adaptive randomization procedures, also guaranteeing the applicability of the classical asymptotic inference. The operating characteristics of the suggested methodology are verified both theoretically and by simulation, including the robustness to model misspecification. With respect to the other available proposals, our strategy always assigns more patients to the best treatment without compromising inference, taking into account estimation efficiency and power as well. We illustrate our procedure by redesigning two real oncological trials.

On a class of optimal covariate-adjusted response adaptive designs for survival outcomes

A class of optimal covariate-adjusted response adaptive procedures is developed for phase III clinical trials when the treatment response is a survival time and there is random censoring. The basic aim is to develop an allocation design by combining the ethical aspects with statistical precision in a reasonable way under the presence of covariate information. Considering minimisation of total hazards as the ethical requirement, the proposed procedure is assessed in terms of the assignment to the better treatment and the efficiency (i.e. power) to detect a small departure in treatment effectiveness. The applicability of the proposed methodology is also illustrated using a real data set.

A Bayesian adaptive design for two-stage clinical trials with survival data

A randomized two-stage adaptive Bayesian design is proposed and studied for allocation and comparison in a phase III clinical trial with survival time as treatment response. Several exact and limiting properties of the design and the follow-up inference are studied, both numerically and theoretically, and are compared with a single-stage randomized procedure. The applicability of the proposed methodology is illustrated by using some real data.

The clinically-integrated randomized trial: proposed novel method for conducting large trials at low cost

INTRODUCTION

Randomized controlled trials provide the best method of determining which of two comparable treatments is preferable. Unfortunately, contemporary randomized trials have become increasingly expensive, complex and burdened by regulation, so much so that many trials are of doubtful feasibility.

DISCUSSION

Here we present a proposal for a novel, streamlined approach to randomized trials: the "clinically-integrated randomized trial". The key aspect of our methodology is that the clinical experience of the patient and doctor is virtually indistinguishable whether or not the patient is randomized, primarily because outcome data are obtained from routine clinical data, or from short, web-based questionnaires. Integration of a randomized trial into routine clinical practice also implies that there should be an attempt to randomize every patient, a corollary of which is that eligibility criteria are minimized. The similar clinical experience of patients on- and off-study also entails that the marginal cost of putting an additional patient on trial is negligible. We propose examples of how the clinically-integrated randomized trial might be applied in four distinct areas of medicine: comparisons of surgical techniques, "me too" drugs, rare diseases and lifestyle interventions. Barriers to implementing clinically-integrated randomized trials are discussed.

CONCLUSION

The proposed clinically-integrated randomized trial may allow us to enlarge dramatically the number of clinical questions that can be addressed by randomization.

Medical and surgical treatment of pyothorax in dogs: 26 cases (1991-2001)

OBJECTIVE

To compare outcomes of dogs with pyothorax treated medically versus surgically and to identify prognostic indicators for dogs with pyothorax.

DESIGN

Retrospective study.

ANIMALS

26 dogs.

PROCEDURE

Medical records were reviewed to obtain information regarding signalment, results of physical and laboratory evaluations at the time of initial examination, results of bacterial culture of pleural fluid, radiographic abnormalities, treatment (surgical vs medical), complications, whether the disease recurred, disease-free interval, survival time, and cause of death.

RESULTS

Calculated proportions of dogs free from disease 1 year after treatment were 25 and 78%, respectively, for dogs treated medically and surgically. Treatment was 5.4 times as likely to fail in dogs treated medically as in dogs treated surgically. Two regression models relating treatment group (medical vs surgical) to disease-free interval were found to be significant. The first contained terms for medical treatment and isolation of Actinomyces spp from pleural fluid; the second contained terms for medical treatment and radiographic detection of mediastinal or pulmonary lesions at the time of initial examination.

CONCLUSIONS AND CLINICAL RELEVANCE

Results suggest that surgical treatment is associated with a better outcome than medical treatment in dogs with pyothorax. In addition, surgery should be considered if radiographic evidence of mediastinal or pulmonary lesions is detected or if Actinomyces spp is isolated from the pleural fluid.

Randomized play-the-winner clinical trials: review and recommendations

The randomized play-the-winner rule is an adaptive randomized design, based on an urn model, that is used occasionally in clinical trials. This paper discusses practical and theoretical issues arising from its use, including stratification, delayed response, operating characteristics, selection of urn parameters, and inference. The paper also discusses recent experience with adaptive clinical trials within the pharmaceutical industry. The author concludes that the randomized play-the-winner rule is appropriate for some clinical trials, but intense and thoughtful planning must take place in the design phase. Such planning should incorporate considerations of variability, power, and appropriate techniques.

A comparison of the randomized play-the-winner rule and the triangular test for clinical trials with binary responses

We consider a clinical trial model comparing an experimental treatment with a control treatment when the responses are binary. For fixed significance level and power, we compare the expected number of treatment failures for two designs--the randomized play-the-winner rule and the triangular test. The former is an example of an adaptive design while the latter is an example of a fully sequential design. We show how to determine the sample size for the randomized play-the-winner rule and how to choose the stopping boundaries for the triangular test so that the two designs have similar power functions. With this choice of design parameters, simulation indicates that the triangular test is generally more effective at reducing the expected number of treatment failures, particularly when there is a large difference between the two probabilities of success. The expected number of treatment failures can be further reduced if the triangular test is applied using the randomized play-the-winner rule to assign each patient to one of the two treatments.