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Parsons SK, Rodday AM, Upshaw JN, Scharman CD, Cui Z, Cao Y, Tiger YKR, Maurer MJ, Evens AM. Harnessing multi-source data for individualized care in Hodgkin Lymphoma. Blood Rev 2024; 65:101170. [PMID: 38290895 DOI: 10.1016/j.blre.2024.101170] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 12/22/2023] [Accepted: 01/11/2024] [Indexed: 02/01/2024]
Abstract
Hodgkin lymphoma is a rare, but highly curative form of cancer, primarily afflicting adolescents and young adults. Despite multiple seminal trials over the past twenty years, there is no single consensus-based treatment approach beyond use of multi-agency chemotherapy with curative intent. The use of radiation continues to be debated in early-stage disease, as part of combined modality treatment, as well as in salvage, as an important form of consolidation. While short-term disease outcomes have varied little across these different approaches across both early and advanced stage disease, the potential risk of severe, longer-term risk has varied considerably. Over the past decade novel therapeutics have been employed in the retrieval setting in preparation to and as consolidation after autologous stem cell transplant. More recently, these novel therapeutics have moved to the frontline setting, initially compared to standard-of-care treatment and later in a direct head-to-head comparison combined with multi-agent chemotherapy. In 2018, we established the HoLISTIC Consortium, bringing together disease and methods experts to develop clinical decision models based on individual patient data to guide providers, patients, and caregivers in decision-making. In this review, we detail the steps we followed to create the master database of individual patient data from patients treated over the past 20 years, using principles of data science. We then describe different methodological approaches we are taking to clinical decision making, beginning with clinical prediction tools at the time of diagnosis, to multi-state models, incorporating treatments and their response. Finally, we describe how simulation modeling can be used to estimate risks of late effects, based on cumulative exposure from frontline and salvage treatment. The resultant database and tools employed are dynamic with the expectation that they will be updated as better and more complete information becomes available.
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Affiliation(s)
- Susan K Parsons
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States of America; Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, United States of America.
| | - Angie Mae Rodday
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States of America
| | - Jenica N Upshaw
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States of America; The CardioVascular Center and Advanced Heart Failure Program, Tufts Medical Center, Boston, MA, United States of America
| | | | - Zhu Cui
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States of America; Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, United States of America
| | - Yenong Cao
- Institute for Clinical Research and Health Policy Studies, Tufts Medical Center, Boston, MA, United States of America; Division of Hematology/Oncology, Tufts Medical Center, Boston, MA, United States of America
| | - Yun Kyoung Ryu Tiger
- Division of Blood Disorders, Rutgers Cancer Institute New Jersey, New Brunswick, NJ, United States of America
| | - Matthew J Maurer
- Division of Clinical Trials and Biostatistics and Division of Hematology, Mayo Clinic, Rochester, MN, United States of America
| | - Andrew M Evens
- Division of Blood Disorders, Rutgers Cancer Institute New Jersey, New Brunswick, NJ, United States of America
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Skourlis N, Crowther MJ, Andersson TML, Lu D, Lambe M, Lambert PC. Exploring different research questions via complex multi-state models when using registry-based repeated prescriptions of antidepressants in women with breast cancer and a matched population comparison group. BMC Med Res Methodol 2023; 23:87. [PMID: 37038100 PMCID: PMC10084660 DOI: 10.1186/s12874-023-01905-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 03/29/2023] [Indexed: 04/12/2023] Open
Abstract
BACKGROUND Multi-state models are used to study several clinically meaningful research questions. Depending on the research question of interest and the information contained in the data, different multi-state structures and modelling choices can be applied. We aim to explore different research questions using a series of multi-state models of increasing complexity when studying repeated prescriptions data, while also evaluating different modelling choices. METHODS We develop a series of research questions regarding the probability of being under antidepressant medication across time using multi-state models, among Swedish women diagnosed with breast cancer (n = 18,313) and an age-matched population comparison group of cancer-free women (n = 92,454) using a register-based database (Breast Cancer Data Base Sweden 2.0). Research questions were formulated ranging from simple to more composite ones. Depending on the research question, multi-state models were built with structures ranging from simpler ones, like single-event survival analysis and competing risks, up to complex bidirectional and recurrent multi-state structures that take into account the recurring start and stop of medication. We also investigate modelling choices, such as choosing a time-scale for the transition rates and borrowing information across transitions. RESULTS Each structure has its own utility and answers a specific research question. However, the more complex structures (bidirectional, recurrent) enable accounting for the intermittent nature of prescribed medication data. These structures deliver estimates of the probability of being under medication and total time spent under medication over the follow-up period. Sensitivity analyses over different definitions of the medication cycle and different choices of timescale when modelling the transition intensity rates show that the estimates of total probabilities of being in a medication cycle over follow-up derived from the complex structures are quite stable. CONCLUSIONS Each research question requires the definition of an appropriate multi-state structure, with more composite ones requiring such an increase in the complexity of the multi-state structure. When a research question is related with an outcome of interest that repeatedly changes over time, such as the medication status based on prescribed medication, the use of novel multi-state models of adequate complexity coupled with sensible modelling choices can successfully address composite, more realistic research questions.
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Affiliation(s)
- Nikolaos Skourlis
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden.
| | | | - Therese M-L Andersson
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
| | - Donghao Lu
- Institute of Environmental Medicine, Karolinska Institutet, Stockholm, Sweden
| | - Mats Lambe
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Regional Cancer Centre Central Sweden, Uppsala, Sweden
| | - Paul C Lambert
- Department of Medical Epidemiology and Biostatistics, Karolinska Institutet, Stockholm, Sweden
- Biostatistics Research Group, Department of Health Sciences, University of Leicester, Leicester, UK
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Smith IL, Nixon JE, Sharples L. Power and sample size for multistate model analysis of longitudinal discrete outcomes in disease prevention trials. Stat Med 2021; 40:1960-1971. [PMID: 33550652 DOI: 10.1002/sim.8882] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2019] [Revised: 12/18/2020] [Accepted: 12/19/2020] [Indexed: 11/11/2022]
Abstract
For clinical trials where participants pass through a number of discrete health states resulting in longitudinal measures over time, there are several potential primary estimands for the treatment effect. Incidence or time to a particular health state are commonly used outcomes but the choice of health state may not be obvious and these estimands do not make full use of the longitudinal assessments. Multistate models have been developed for some diseases and conditions with the purpose of understanding their natural history and have been used for secondary analysis to understand mechanisms of action of treatments. There is little published on the use of multistate models as the primary analysis method and potential implications on design features, such as assessment schedules. We illustrate methods via analysis of data from a motivating example; a Phase III clinical trial of pressure ulcer prevention strategies. We clarify some of the possible estimands that might be considered and we show, via a simulation study, that under some circumstances the sample size could be reduced by half using a multistate model based analysis, without adversely affecting the power of the trial.
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Affiliation(s)
| | - Jane E Nixon
- Clinical Trials Research Unit, University of Leeds, Leeds, UK
| | - Linda Sharples
- Department of Medical Statistics, London School of Hygiene and Tropical Medicine, London, UK
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Bluhmki T, Schmoor C, Finke J, Schumacher M, Socié G, Beyersmann J. Relapse- and Immunosuppression-Free Survival after Hematopoietic Stem Cell Transplantation: How Can We Assess Treatment Success for Complex Time-to-Event Endpoints? Biol Blood Marrow Transplant 2020; 26:992-997. [PMID: 31927103 DOI: 10.1016/j.bbmt.2020.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 12/02/2019] [Accepted: 01/03/2020] [Indexed: 12/26/2022]
Abstract
In most clinical oncology trials, time-to-first-event analyses are used for efficacy assessment, which often do not capture the entire disease process. Instead, the focus may be on more complex time-to-event endpoints, such as the course of disease after the first event or endpoints occurring after randomization. We propose "relapse- and immunosuppression-free survival" (RIFS) as an innovative and clinically relevant outcome measure for assessing treatment success after hematopoietic stem cell transplant (SCT). To capture the time-dynamic relationship of multiple episodes of immunosuppressive therapy during follow-up, relapse, and nonrelapse mortality, a multistate model was developed. The statistical complexity is that the probability of RIFS is nonmonotonic over time; thus, standard time-to-first-event methodology is inappropriate for formal treatment comparisons. Instead, a generalization of the Kaplan-Meier method was used for probability estimation, and simulation-based resampling was suggested as a strategy for statistical inference. We reanalyzed data from a recently published phase III trial in 201 leukemia patients after SCT. The study evaluated long-term treatment success of standard graft-versus-host disease prophylaxis plus a pretransplant antihuman T-lymphocyte immunoglobulin compared with standard prophylaxis alone. Results suggested that treatment increased the long-term probability of RIFS by approximately 30% during the entire follow-up period, which complements the original findings. This article highlights the importance of complex endpoints in oncology, which provide deeper insight into the treatment and disease process over time. Multistate models combined with resampling are highlighted as a promising tool to evaluate treatment success beyond standard endpoints. An example code is provided in the Supplementary Materials.
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Affiliation(s)
| | - Claudia Schmoor
- Clinical Trials Unit, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Jürgen Finke
- Department of Hematology, Oncology, and Stem-Cell Transplantation, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Martin Schumacher
- Institute for Medical Biometry and Medical Statistics, Faculty of Medicine and Medical Center, University of Freiburg, Freiburg, Germany
| | - Gérard Socié
- Université de Paris, INSERM U976 and Hématologie-Transplantation, Hôpital St. Louis, Paris, France
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Farcomeni A, Geraci M. Multistate quantile regression models. Stat Med 2019; 39:45-56. [DOI: 10.1002/sim.8393] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 09/20/2019] [Accepted: 09/21/2019] [Indexed: 01/09/2023]
Affiliation(s)
- Alessio Farcomeni
- Department of Economics and FinanceUniversity of Rome “Tor Vergata” Rome Italy
| | - Marco Geraci
- Department of Epidemiology and Biostatistics, Arnold School of Public HealthUniversity of South Carolina Columbia South Carolina
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Tassistro E, Bernasconi DP, Rebora P, Valsecchi MG, Antolini L. Modeling the hazard of transition into the absorbing state in the illness-death model. Biom J 2019; 62:836-851. [PMID: 31515830 DOI: 10.1002/bimj.201800267] [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: 08/30/2018] [Revised: 05/21/2019] [Accepted: 06/12/2019] [Indexed: 11/08/2022]
Abstract
The illness-death model is the simplest multistate model where the transition from the initial state 0 to the absorbing state 2 may involve an intermediate state 1 (e.g., disease relapse). The impact of the transition into state 1 on the subsequent transition hazard to state 2 enables insight to be gained into the disease evolution. The standard approach of analysis is modeling the transition hazards from 0 to 2 and from 1 to 2, including time to illness as a time-varying covariate and measuring time from origin even after transition into state 1. The hazard from 1 to 2 can be also modeled separately using only patients in state 1, measuring time from illness and including time to illness as a fixed covariate. A recently proposed approach is a model where time after the transition into state 1 is measured in both scales and time to illness is included as a time-varying covariate. Another possibility is a model where time after transition into state 1 is measured only from illness and time to illness is included as a fixed covariate. Through theoretical reasoning and simulation protocols, we discuss the use of these models and we develop a practical strategy aiming to (a) validate the properties of the illness-death process, (b) estimate the impact of time to illness on the hazard from state 1 to 2, and (c) quantify the impact that the transition into state 1 has on the hazard of the absorbing state. The strategy is also applied to a literature dataset on diabetes.
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Affiliation(s)
- Elena Tassistro
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Davide Paolo Bernasconi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Paola Rebora
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Maria Grazia Valsecchi
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | - Laura Antolini
- Center of Biostatistics for Clinical Epidemiology, School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
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