A general class of Bayesian survival models with zero and nonzero cure fractions

We propose a new class of survival models which naturally links a family of proper and improper population survival functions. The models resulting in improper survival functions are often referred to as cure rate models. This class of regression models is formulated through the Box-Cox transformation on the population hazard function and a proper density function. By adding an extra transformation parameter into the cure rate model, we are able to generate models with a zero cure rate, thus leading to a proper population survival function. A graphical illustration of the behavior and the influence of the transformation parameter on the regression model is provided. We consider a Bayesian approach which is motivated by the complexity of the model. Prior specification needs to accommodate parameter constraints due to the non-negativity of the survival function. Moreover, the likelihood function involves a complicated integral on the survival function, which may not have an analytical closed form, and thus makes the implementation of Gibbs sampling more difficult. We propose an efficient Markov chain Monte Carlo computational scheme based on Gaussian quadrature. The proposed method is illustrated with an example involving a melanoma clinical trial.     

Mean residual life cure models for right-censored data with and without length-biased sampling

We propose a semiparametric mean residual life mixture cure model for right-censored survival data with a cured fraction. The model employs the proportional mean residual life model to describe the effects of covariates on the mean residual time of uncured subjects and the logistic regression model to describe the effects of covariates on the cure rate. We develop estimating equations to estimate the proposed cure model for the right-censored data with and without length-biased sampling, the latter is often found in prevalent cohort studies. In particular, we propose two estimating equations to estimate the effects of covariates in the cure rate and a method to combine them to improve the estimation efficiency. The consistency and asymptotic normality of the proposed estimates are established. The finite sample performance of the estimates is confirmed with simulations. The proposed estimation methods are applied to a clinical trial study on melanoma and a prevalent cohort study on early-onset type 2 diabetes mellitus.     

Joint model for recurrent event data with a cured fraction and a terminal event

In a longitudinal study where the recurrence of an event and a terminal event such as death are observed, a certain portion of the subjects may experience no event during a long follow-up period; this often denoted as the cure group which is assumed to be the risk-free from both recurrent events and death. However, this assumption ignores the possibility of death, which subjects in the cure group may experience. In the present study, such misspecification is investigated with the addition of a death hazard model to the cure group. We propose a joint model using a frailty effect, which reflects the association between a recurrent event and death. For the estimation, an expectation-maximization (EM) algorithm was developed and PROC NLMIXED in SAS was incorporated under a piecewise constant baseline. Simulation studies were performed to check the performance of the suggested method. The proposed method was applied to leukemia patients experiencing both infection and death after bone marrow transplant.     

A bivariate joint frailty model with mixture framework for survival analysis of recurrent events with dependent censoring and cure fraction

In the study of multiple failure time data with recurrent clinical endpoints, the classical independent censoring assumption in survival analysis can be violated when the evolution of the recurrent events is correlated with a censoring mechanism such as death. Moreover, in some situations, a cure fraction appears in the data because a tangible proportion of the study population benefits from treatment and becomes recurrence free and insusceptible to death related to the disease. A bivariate joint frailty mixture cure model is proposed to allow for dependent censoring and cure fraction in recurrent event data. The latency part of the model consists of two intensity functions for the hazard rates of recurrent events and death, wherein a bivariate frailty is introduced by means of the generalized linear mixed model methodology to adjust for dependent censoring. The model allows covariates and frailties in both the incidence and the latency parts, and it further accounts for the possibility of cure after each recurrence. It includes the joint frailty model and other related models as special cases. An expectation-maximization (EM)-type algorithm is developed to provide residual maximum likelihood estimation of model parameters. Through simulation studies, the performance of the model is investigated under different magnitudes of dependent censoring and cure rate. The model is applied to data sets from two colorectal cancer studies to illustrate its practical value.     

A cure‐rate model for Q‐learning: Estimating an adaptive immunosuppressant treatment strategy for allogeneic hematopoietic cell transplant patients

Cancers treated by transplantation are often curative, but immunosuppressive drugs are required to prevent and (if needed) to treat graft‐versus‐host disease. Estimation of an optimal adaptive treatment strategy when treatment at either one of two stages of treatment may lead to a cure has not yet been considered. Using a sample of 9563 patients treated for blood and bone cancers by allogeneic hematopoietic cell transplantation drawn from the Center for Blood and Marrow Transplant Research database, we provide a case study of a novel approach to Q‐learning for survival data in the presence of a potentially curative treatment, and demonstrate the results differ substantially from an implementation of Q‐learning that fails to account for the cure‐rate.     

Nonparametric confidence intervals for the ratio of marginal hazard rates of paired survival times

Paired survival times with potential censoring are often observed from two treatment groups in clinical trials and other types of clinical studies. The ratio of marginal hazard rates may be used to quantify the treatment effect in these studies. In this paper, a recently proposed nonparametric kernel method is used to estimate the marginal hazard rate, and the method of variance estimates recovery (MOVER) is used for the construction of the confidence intervals of a time‐dependent hazard ratio based on the confidence limits of a single marginal hazard rate. Two methods are proposed: one uses the delta method and another adopts the transformation method to construct confidence limits for the marginal hazard rate. Simulations are performed to evaluate the performance of the proposed methods. Real data from two clinical trials are analyzed using the proposed methods.     

Joint models for multivariate longitudinal and multivariate survival data

Joint modeling of longitudinal and survival data is becoming increasingly essential in most cancer and AIDS clinical trials. We propose a likelihood approach to extend both longitudinal and survival components to be multidimensional. A multivariate mixed effects model is presented to explicitly capture two different sources of dependence among longitudinal measures over time as well as dependence between different variables. For the survival component of the joint model, we introduce a shared frailty, which is assumed to have a positive stable distribution, to induce correlation between failure times. The proposed marginal univariate survival model, which accommodates both zero and nonzero cure fractions for the time to event, is then applied to each marginal survival function. The proposed multivariate survival model has a proportional hazards structure for the population hazard, conditionally as well as marginally, when the baseline covariates are specified through a specific mechanism. In addition, the model is capable of dealing with survival functions with different cure rate structures. The methodology is specifically applied to the International Breast Cancer Study Group (IBCSG) trial to investigate the relationship between quality of life, disease-free survival, and overall survival.     

Estimating and modeling the cure fraction in population-based cancer survival analysis

In population-based cancer studies, cure is said to occur when the mortality (hazard) rate in the diseased group of individuals returns to the same level as that expected in the general population. The cure fraction (the proportion of patients cured of disease) is of interest to patients and is a useful measure to monitor trends in survival of curable disease. There are 2 main types of cure fraction model, the mixture cure fraction model and the non-mixture cure fraction model, with most previous work concentrating on the mixture cure fraction model. In this paper, we extend the parametric non-mixture cure fraction model to incorporate background mortality, thus providing estimates of the cure fraction in population-based cancer studies. We compare the estimates of relative survival and the cure fraction between the 2 types of model and also investigate the importance of modeling the ancillary parameters in the selected parametric distribution for both types of model.     

Analysis of Detection Processes for Breast Cancer

Most existing records of detection processes for breast cancer are in the form of cancer registries or are results of large clinical trials. Statistical modelling can be applied to these data sets to study various properties of breast cancer. In particular we estimate the probability of cure given the size of the tumour at detection, the distribution of tumour growth rates and the distribution of the size of the tumour at detection. There has been a strong recent interest in early detection methods. These consist of giving regular examinations, called screenings. The effect of screening design on the probability of cure is considered. The results of an existing screening trial are used to derive another estimate of the tumour growth rate distribution which agrees well both with our earlier estimate and the most widely used empirical estimate in the literature. The calculation of lead time, which is the time gained in detection when screenings are given, is also discussed.     

Bayesian cure rate frailty models with application to a root canal therapy study

Due to natural or artificial clustering, multivariate survival data often arise in biomedical studies, for example, a dental study involving multiple teeth from each subject. A certain proportion of subjects in the population who are not expected to experience the event of interest are considered to be "cured" or insusceptible. To model correlated or clustered failure time data incorporating a surviving fraction, we propose two forms of cure rate frailty models. One model naturally introduces frailty based on biological considerations while the other is motivated from the Cox proportional hazards frailty model. We formulate the likelihood functions based on piecewise constant hazards and derive the full conditional distributions for Gibbs sampling in the Bayesian paradigm. As opposed to the Cox frailty model, the proposed methods demonstrate great potential in modeling multivariate survival data with a cure fraction. We illustrate the cure rate frailty models with a root canal therapy data set.     

Extinct or still out there? Disentangling influences on extinction and rediscovery helps to clarify the fate of species on the edge

Each year, two or three species that had been considered to be extinct are rediscovered. Uncertainty about whether or not a species is extinct is common, because rare and highly threatened species are difficult to detect. Biological traits such as body size and range size are expected to be associated with extinction. However, these traits, together with the intensity of search effort, might influence the probability of detection and extinction differently. This makes statistical analysis of extinction and rediscovery challenging. Here, we use a variant of survival analysis known as cure rate modelling to differentiate factors that influence rediscovery from those that influence extinction. We analyse a global data set of 99 mammals that have been categorized as extinct or possibly extinct. We estimate the probability that each of these mammals is still extant and thus estimate the proportion of missing (presumed extinct) mammals that are incorrectly assigned extinction. We find that body mass and population density are predictors of extinction, and body mass and search effort predict rediscovery. In mammals, extinction rate increases with body mass and population density, and these traits act synergistically to greatly elevate extinction rate in large species that also occurred in formerly dense populations. However, when they remain extant, larger‐bodied missing species are rediscovered sooner than smaller species. Greater search effort increases the probability of rediscovery in larger species of missing mammals, but has a minimal effect on small species, which take longer to be rediscovered, if extant. By separating the effects of species characteristics on extinction and detection, and using models with the assumption that a proportion of missing species will never be rediscovered, our new approach provides estimates of extinction probability in species with few observation records and scant ecological information.     

On a class of non-linear transformation cure rate models

In this paper, we propose a generalization of the mixture (binary) cure rate model, motivated by the existence of a zero-modified (inflation or deflation) distribution, on the initial number of causes, under a competing cause scenario. This non-linear transformation cure rate model is in the same form of models studied in the past; however, following our approach, we are able to give a realistic interpretation to a specific class of proper transformation functions, for the cure rate modeling. The estimation of the parameters is then carried out using the maximum likelihood method along with a profile approach. A simulation study examines the accuracy of the proposed estimation method and the model discrimination based on the likelihood ratio test. For illustrative purposes, analysis of two real life data-sets, one on recidivism and another on cutaneous melanoma, is also carried out.     

Matching Methods for Obtaining Survival Functions to Estimate the Effect of a Time-Dependent Treatment

In observational studies of survival time featuring a binary time-dependent treatment, the hazard ratio (an instantaneous measure) is often used to represent the treatment effect. However, investigators are often more interested in the difference in survival functions. We propose semiparametric methods to estimate the causal effect of treatment among the treated with respect to survival probability. The objective is to compare post-treatment survival with the survival function that would have been observed in the absence of treatment. For each patient, we compute a prognostic score (based on the pre-treatment death hazard) and a propensity score (based on the treatment hazard). Each treated patient is then matched with an alive, uncensored and not-yet-treated patient with similar prognostic and/or propensity scores. The experience of each treated and matched patient is weighted using a variant of Inverse Probability of Censoring Weighting to account for the impact of censoring. We propose estimators of the treatment-specific survival functions (and their difference), computed through weighted Nelson–Aalen estimators. Closed-form variance estimators are proposed which take into consideration the potential replication of subjects across matched sets. The proposed methods are evaluated through simulation, then applied to estimate the effect of kidney transplantation on survival among end-stage renal disease patients using data from a national organ failure registry.     

The influence of local environment on the aging and mortality ofAedes aegypti (L.): Case study in Fortaleza‐CE,Brazil

It is generally assumed that the daily probability of survival of mosquitoes is independent of age. To test this assumption we have conducted a three‐year experimental fieldwork study (2005–2007) at Fortaleza‐CE in Brazil, determining daily survival rates of the dengue vector Aedes aegypti (L.). Survival rates of adult Ae. aegypti may be age‐dependent and the statistical analysis is a sensitive approach for comparing patterns of mosquito survival. The mosquito survival data were better fit by a Weibull survival function than by the more traditionally used Gompertz or logistic survival functions. Gompertz, Weibull, or logistic survival functions often fit the survival, and the tails of the survival curves usually appear to fall between the values predicted by the three functions. We corroborate that the mortality of Ae. aegypti in semi‐natural conditions may no more be considered as a constant phenomenon during the life of adult mosquitoes but varies according to the age and environmental conditions under a tropical climate. This study estimates the variability in the survival rate of Ae. aegypti and environmental factors that are related to such variability. The statistical analysis shows that the fitting ability, concerning the hazard function, was in decreasing order: Seasonal Cox, the three‐parameter Gompertz, and the three‐parameter Weibull, that was similar to the three‐parameter logistic. The advantage of using the Cox model is that it is convenient for exploring the relationship between survival and several explanatory variables. The Cox model has the advantage of preserving the variable in its original quantitative form and of using a maximum of information. The survival analyses indicate that mosquito mortality is both age‐ and environment‐dependent.     

Semiparametric transformation models for interval‐censored data in the presence of a cure fraction

Mixed case interval‐censored data arise when the event of interest is known only to occur within an interval induced by a sequence of random examination times. Such data are commonly encountered in disease research with longitudinal follow‐up. Furthermore, the medical treatment has progressed over the last decade with an increasing proportion of patients being cured for many types of diseases. Thus, interest has grown in cure models for survival data which hypothesize a certain proportion of subjects in the population are not expected to experience the events of interest. In this article, we consider a two‐component mixture cure model for regression analysis of mixed case interval‐censored data. The first component is a logistic regression model that describes the cure rate, and the second component is a semiparametric transformation model that describes the distribution of event time for the uncured subjects. We propose semiparametric maximum likelihood estimation for the considered model. We develop an EM type algorithm for obtaining the semiparametric maximum likelihood estimators (SPMLE) of regression parameters and establish their consistency, efficiency, and asymptotic normality. Extensive simulation studies indicate that the SPMLE performs satisfactorily in a wide variety of settings. The proposed method is illustrated by the analysis of the hypobaric decompression sickness data from National Aeronautics and Space Administration.     

A statistical model for red blood cell survival

A statistical model for the survival time of red blood cells (RBCs) with a continuous distribution of cell lifespans is presented. The underlying distribution of RBC lifespans is derived from a probability density function with a bathtub-shaped hazard curve, and accounts for death of RBCs due to senescence (age-dependent increasing hazard rate) and random destruction (constant hazard), as well as for death due to initial or delayed failures and neocytolysis (equivalent to early red cell mortality). The model yields survival times similar to those of previously published studies of RBC survival and is easily amenable to inclusion of drug effects and haemolytic disorders.     

Multilevel Mixture Cure Models with Random Effects

This paper extends the multilevel survival model by allowing the existence of cured fraction in the model. Random effects induced by the multilevel clustering structure are specified in the linear predictors in both hazard function and cured probability parts. Adopting the generalized linear mixed model (GLMM) approach to formulate the problem, parameter estimation is achieved by maximizing a best linear unbiased prediction (BLUP) type log‐likelihood at the initial step of estimation, and is then extended to obtain residual maximum likelihood (REML) estimators of the variance component. The proposed multilevel mixture cure model is applied to analyze the (i) child survival study data with multilevel clustering and (ii) chronic granulomatous disease (CGD) data on recurrent infections as illustrations. A simulation study is carried out to evaluate the performance of the REML estimators and assess the accuracy of the standard error estimates.     

Generalized parametric cure models for relative survival

Cure models are used in time-to-event analysis when not all individuals are expected to experience the event of interest, or when the survival of the considered individuals reaches the same level as the general population. These scenarios correspond to a plateau in the survival and relative survival function, respectively. The main parameters of interest in cure models are the proportion of individuals who are cured, termed the cure proportion, and the survival function of the uncured individuals. Although numerous cure models have been proposed in the statistical literature, there is no consensus on how to formulate these. We introduce a general parametric formulation of mixture cure models and a new class of cure models, termed latent cure models, together with a general estimation framework and software, which enable fitting of a wide range of different models. Through simulations, we assess the statistical properties of the models with respect to the cure proportion and the survival of the uncured individuals. Finally, we illustrate the models using survival data on colon cancer, which typically display a plateau in the relative survival. As demonstrated in the simulations, mixture cure models which are not guaranteed to be constant after a finite time point, tend to produce accurate estimates of the cure proportion and the survival of the uncured. However, these models are very unstable in certain cases due to identifiability issues, whereas LC models generally provide stable results at the price of more biased estimates.     

Estimating the proportion cured of cancer: Some practical advice for users

BackgroundCure models can provide improved possibilities for inference if used appropriately, but there is potential for misleading results if care is not taken. In this study, we compared five commonly used approaches for modelling cure in a relative survival framework and provide some practical advice on the use of these approaches.Patients and methodsData for colon, female breast, and ovarian cancers were used to illustrate these approaches. The proportion cured was estimated for each of these three cancers within each of three age groups. We then graphically assessed the assumption of cure and the model fit, by comparing the predicted relative survival from the cure models to empirical life table estimates.ResultsWhere both cure and distributional assumptions are appropriate (e.g., for colon or ovarian cancer patients aged <75 years), all five approaches led to similar estimates of the proportion cured. The estimates varied slightly when cure was a reasonable assumption but the distributional assumption was not (e.g., for colon cancer patients ≥75 years). Greater variability in the estimates was observed when the cure assumption was not supported by the data (breast cancer).ConclusionsIf the data suggest cure is not a reasonable assumption then we advise against fitting cure models. In the scenarios where cure was reasonable, we found that flexible parametric cure models performed at least as well, or better, than the other modelling approaches. We recommend that, regardless of the model used, the underlying assumptions for cure and model fit should always be graphically assessed.     

Evolutionary Invasion and Escape in the Presence of Deleterious Mutations

Replicators such as parasites invading a new host species, species invading a new ecological niche, or cancer cells invading a new tissue often must mutate to adapt to a new environment. It is often argued that a higher mutation rate will favor evolutionary invasion and escape from extinction. However, most mutations are deleterious, and even lethal. We study the probability that the lineage will survive and invade successfully as a function of the mutation rate when both the initial strain and an adaptive mutant strain are threatened by lethal mutations. We show that mutations are beneficial, i.e. a non-zero mutation rate increases survival compared to the limit of no mutations, if in the no-mutation limit the survival probability of the initial strain is smaller than the average survival probability of the strains which are one mutation away. The mutation rate that maximizes survival depends on the characteristics of both the initial strain and the adaptive mutant, but if one strain is closer to the threshold governing survival then its properties will have greater influence. These conclusions are robust for more realistic or mechanistic depictions of the fitness landscapes such as a more detailed viral life history, or non-lethal deleterious mutations.