A conditional error function approach for adaptive enrichment designs with continuous endpoints

Blinded sample size recalculation in multiple composite population designs with normal data and baseline adjustments

The increasing interest in subpopulation analysis has led to the development of various new trial designs and analysis methods in the fields of personalized medicine and targeted therapies. In this paper, subpopulations are defined in terms of an accumulation of disjoint population subsets and will therefore be called composite populations. The proposed trial design is applicable to any set of composite populations, considering normally distributed endpoints and random baseline covariates. Treatment effects for composite populations are tested by combining p-values, calculated on the subset levels, using the inverse normal combination function to generate test statistics for those composite populations while the closed testing procedure accounts for multiple testing. Critical boundaries for intersection hypothesis tests are derived using multivariate normal distributions, reflecting the joint distribution of composite population test statistics given no treatment effect exists. For sample size calculation and sample size, recalculation multivariate normal distributions are derived which describe the joint distribution of composite population test statistics under an assumed alternative hypothesis. Simulations demonstrate the absence of any practical relevant inflation of the type I error rate. The target power after sample size recalculation is typically met or close to being met.

New insights into adaptive enrichment designs

The transition towards personalized medicine is happening and the new experimental framework is raising several challenges, from a clinical, ethical, logistical, regulatory, and statistical perspective. To face these challenges, innovative study designs with increasing complexity have been proposed. In particular, adaptive enrichment designs are becoming more attractive for their flexibility. However, these procedures rely on an increasing number of parameters that are unknown at the planning stage of the clinical trial, so the study design requires particular care. This review is dedicated to adaptive enrichment studies with a focus on design aspects. While many papers deal with methods for the analysis, the sample size determination and the optimal allocation problem have been overlooked. We discuss the multiple aspects involved in adaptive enrichment designs that contribute to their advantages and disadvantages. The decision-making process of whether or not it is worth enriching should be driven by clinical and ethical considerations as well as scientific and statistical concerns.

The population-wise error rate for clinical trials with overlapping populations

We introduce a new multiple type I error criterion for clinical trials with multiple, overlapping populations. Such trials are of interest in precision medicine where the goal is to develop treatments that are targeted to specific sub-populations defined by genetic and/or clinical biomarkers. The new criterion is based on the observation that not all type I errors are relevant to all patients in the overall population. If disjoint sub-populations are considered, no multiplicity adjustment appears necessary, since a claim in one sub-population does not affect patients in the other ones. For intersecting sub-populations we suggest to control the average multiple type I error rate, i.e. the probability that a randomly selected patient will be exposed to an inefficient treatment. We call this the population-wise error rate, exemplify it by a number of examples and illustrate how to control it with an adjustment of critical boundaries or adjusted p-values. We furthermore define corresponding simultaneous confidence intervals. We finally illustrate the power gain achieved by passing from family-wise to population-wise error rate control with two simple examples and a recently suggested multiple-testing approach for umbrella trials.

Blinded sample size recalculation in adaptive enrichment designs

In the precision medicine era, (prespecified) subgroup analyses are an integral part of clinical trials. Incorporating multiple populations and hypotheses in the design and analysis plan, adaptive designs promise flexibility and efficiency in such trials. Adaptations include (unblinded) interim analyses (IAs) or blinded sample size reviews. An IA offers the possibility to select promising subgroups and reallocate sample size in further stages. Trials with these features are known as adaptive enrichment designs. Such complex designs comprise many nuisance parameters, such as prevalences of the subgroups and variances of the outcomes in the subgroups. Additionally, a number of design options including the timepoint of the sample size review and timepoint of the IA have to be selected. Here, for normally distributed endpoints, we propose a strategy combining blinded sample size recalculation and adaptive enrichment at an IA, that is, at an early timepoint nuisance parameters are reestimated and the sample size is adjusted while subgroup selection and enrichment is performed later. We discuss implications of different scenarios concerning the variances as well as the timepoints of blinded review and IA and investigate the design characteristics in simulations. The proposed method maintains the desired power if planning assumptions were inaccurate and reduces the sample size and variability of the final sample size when an enrichment is performed. Having two separate timepoints for blinded sample size review and IA improves the timing of the latter and increases the probability to correctly enrich a subgroup.

Classification of Companion Diagnostics: A New Framework for Biomarker-Driven Patient Selection

Background

Modern personalized medicine strategies builds on therapy companion diagnostics to stratify patients into subgroups with differential benefit/risk. In general, stratification for drug response implies a treatment-by-subgroup interaction. This interaction is usually suggested by the drug’s mechanism of action and investigated in pharmacological research or in clinical studies. In these candidate genes or pathway approaches, either biological reasons for a differential benefit/risk or statistical interaction regarding a pharmacological or clinical endpoint or both may be given. For successful drug approval, demonstration of a positive benefit/risk balance in the intended patient population is required. This also applies to situations with biomarker-selected populations. However, further regulatory considerations relate to the usefulness and plausibility of the selected patients and benefit/risk extrapolations or alternative therapy options in biomarker-negative populations.

Methods

To facilitate the specification of regulatory requirements and support the design of clinical development programmes, a systematic classification of biomarker-drug pairs is needed, in particular with regard to the expected underlying molecular mechanism and the clinical evidence.

Results

A classification of five biomarker-drug categories is proposed related to increasing evidence on the biomarker’s predictive value in relation to a specific drug. We classified biomarkers into five ascending categories with increasing evidence on the predictive nature of the biomarker in relation to a specific drug according to the comparative pharmacological and clinical evidence.

Conclusions

The proposed classification will facilitate regulatory decision-making and support drug development with respect to biomarker-related subgrouping, both, during clinical programme and at the time of marketing authorization application, since the grade of evidence on the differential power of the biomarker can be considered as an indicator for the usefulness of a biomarker-related subgrouping.

Adaptive seamless clinical trials using early outcomes for treatment or subgroup selection: Methods, simulation model and their implementation in R

Adaptive seamless designs combine confirmatory testing, a domain of phase III trials, with features such as treatment or subgroup selection, typically associated with phase II trials. They promise to increase the efficiency of development programmes of new drugs, for example, in terms of sample size and/or development time. It is well acknowledged that adaptive designs are more involved from a logistical perspective and require more upfront planning, often in the form of extensive simulation studies, than conventional approaches. Here, we present a framework for adaptive treatment and subgroup selection using the same notation, which links the somewhat disparate literature on treatment selection on one side and on subgroup selection on the other. Furthermore, we introduce a flexible and efficient simulation model that serves both designs. As primary endpoints often take a long time to observe, interim analyses are frequently informed by early outcomes. Therefore, all methods presented accommodate interim analyses informed by either the primary outcome or an early outcome. The R package asd, previously developed to simulate designs with treatment selection, was extended to include subgroup selection (so‐called adaptive enrichment designs). Here, we describe the functionality of the R package asd and use it to present some worked‐up examples motivated by clinical trials in chronic obstructive pulmonary disease and oncology. The examples both illustrate various features of the R package and provide insights into the operating characteristics of adaptive seamless studies.