Effects of measured susceptibility genes on cancer risk in family studies

Numerous family studies have been performed to assess the associations between cancer incidence and genetic and non-genetic risk factors and to quantitatively evaluate the cancer risk attributable to these factors. However, mathematical models that account for a measured hereditary susceptibility gene have not been fully explored in family studies. In this report, we proposed statistical approaches to precisely model a measured susceptibility gene fitted to family data and simultaneously determine the combined effects of individual risk factors and their interactions. Our approaches are structured for age-specific risk models based on Cox proportional hazards regression methods. They are useful for analyses of families and extended pedigrees in which measured risk genotypes are segregated within the family and are robust even when the genotypes are available only in some members of a family. We exemplified these methods by analyzing six extended pedigrees ascertained through soft-tissue sarcoma patients with p53 germ-line mutations. Our analyses showed that germ-line p53 mutations and sex had significant interaction effects on cancer risk. Our proposed methods in family studies are accurate and robust for assessing age-specific cancer risk attributable to a measured hereditary susceptibility gene, providing valuable inferences for genetic counseling and clinical management.     

Marginal hazard ratio estimates in joint frailty models for heart failure trials

This work is motivated by clinical trials in chronic heart failure disease, where treatment has effects both on morbidity (assessed as recurrent non‐fatal hospitalisations) and on mortality (assessed as cardiovascular death, CV death). Recently, a joint frailty proportional hazards model has been proposed for these kind of efficacy outcomes to account for a potential association between the risk rates for hospital admissions and CV death. However, more often clinical trial results are presented by treatment effect estimates that have been derived from marginal proportional hazards models, that is, a Cox model for mortality and an Andersen–Gill model for recurrent hospitalisations. We show how these marginal hazard ratios and their estimates depend on the association between the risk processes, when these are actually linked by shared or dependent frailty terms. First we derive the marginal hazard ratios as a function of time. Then, applying least false parameter theory, we show that the marginal hazard ratio estimate for the hospitalisation rate depends on study duration and on parameters of the underlying joint frailty model. In particular, we identify parameters, for example the treatment effect on mortality, that determine if the marginal hazard ratio estimate for hospitalisations is smaller, equal or larger than the conditional one. How this affects rejection probabilities is further investigated in simulation studies. Our findings can be used to interpret marginal hazard ratio estimates in heart failure trials and are illustrated by the results of the CHARM‐Preserved trial (where CHARM is the ‘Candesartan in Heart failure Assessment of Reduction in Mortality and morbidity’ programme).     

Polynomial spline estimation and inference of proportional hazards regression models with flexible relative risk form

The Cox proportional hazards model usually assumes an exponential form for the dependence of the hazard function on covariate variables. However, in practice this assumption may be violated and other relative risk forms may be more appropriate. In this article, we consider the proportional hazards model with an unknown relative risk form. Issues in model interpretation are addressed. We propose a method to estimate the relative risk form and the regression parameters simultaneously by first approximating the logarithm of the relative risk form by a spline, and then employing the maximum partial likelihood estimation. An iterative alternating optimization procedure is developed for efficient implementation. Statistical inference of the regression coefficients and of the relative risk form based on parametric asymptotic theory is discussed. The proposed methods are illustrated using simulation and an application to the Veteran's Administration lung cancer data.     

Estimating Attributable Life Expectancy Under the Proportional Mean Residual Life Model

In population-based health research, the so-called population attributable fraction is an important quantity that calculates the percentage of excess risk of morbidity and mortality associated with modifiable risk factors for a given population. While the concept of “risk” is usually measured by event probabilities, in practice it may be of a more direct interest to know the excess life expectancy associated with the modifiable risk factors instead, particularly when mortality is of the ultimate concern. In this paper, we thus propose to study a novel quantity, termed “attributable life expectancy,” to measure the population attributable fraction of life expectancy. We further develop a model-based approach for the attributable life expectancy under the Oakes–Dasu proportional mean residual life model, and establish its asymptotic properties for inferences. Numerical studies that include Monte-Carlo simulations and an actual analysis of the mortality associated with smoking cessation in an Asia Cohort Consortium are conducted to evaluate the performance of our proposed method.

     

A General Class of Semiparametric Transformation Frailty Models for Nonproportional Hazards Survival Data

Summary We propose a semiparametrically efficient estimation of a broad class of transformation regression models for nonproportional hazards data. Classical transformation models are to be viewed from a frailty model paradigm, and the proposed method provides a unified approach that is valid for both continuous and discrete frailty models. The proposed models are shown to be flexible enough to model long‐term follow‐up survival data when the treatment effect diminishes over time, a case for which the PH or proportional odds assumption is violated, or a situation in which a substantial proportion of patients remains cured after treatment. Estimation of the link parameter in frailty distribution, considered to be unknown and possibly dependent on a time‐independent covariates, is automatically included in the proposed methods. The observed information matrix is computed to evaluate the variances of all the parameter estimates. Our likelihood‐based approach provides a natural way to construct simple statistics for testing the PH and proportional odds assumptions for usual survival data or testing the short‐ and long‐term effects for survival data with a cure fraction. Simulation studies demonstrate that the proposed inference procedures perform well in realistic settings. Applications to two medical studies are provided.     

Statistical Methods for Analyzing Right‐Censored Length‐Biased Data under Cox Model

Summary Length‐biased time‐to‐event data are commonly encountered in applications ranging from epidemiological cohort studies or cancer prevention trials to studies of labor economy. A longstanding statistical problem is how to assess the association of risk factors with survival in the target population given the observed length‐biased data. In this article, we demonstrate how to estimate these effects under the semiparametric Cox proportional hazards model. The structure of the Cox model is changed under length‐biased sampling in general. Although the existing partial likelihood approach for left‐truncated data can be used to estimate covariate effects, it may not be efficient for analyzing length‐biased data. We propose two estimating equation approaches for estimating the covariate coefficients under the Cox model. We use the modern stochastic process and martingale theory to develop the asymptotic properties of the estimators. We evaluate the empirical performance and efficiency of the two methods through extensive simulation studies. We use data from a dementia study to illustrate the proposed methodology, and demonstrate the computational algorithms for point estimates, which can be directly linked to the existing functions in S‐PLUS or R .     

A Joint Modeling Approach for Longitudinal Data with Informative Observation Times and a Terminal Event

In this article, we propose a new joint modeling approach for the analysis of longitudinal data with informative observation times and a dependent terminal event. We specify a semiparametric mixed effects model for the longitudinal process, a proportional rate frailty model for the observation process, and a proportional hazards frailty model for the terminal event. The association among the three related processes is modeled via two latent variables. Estimating equation approaches are developed for parameter estimation, and the asymptotic properties of the proposed estimators are established. The finite sample performance of the proposed estimators is examined through simulation studies, and an application to a medical cost study of chronic heart failure patients is illustrated.     

A haplotype-based test of association using data from cohort and nested case-control epidemiologic studies

Haplotype-based risk models can lead to powerful methods for detecting the association of a disease with a genomic region of interest. In population-based studies of unrelated individuals, however, the haplotype status of some subjects may not be discernible without ambiguity from available locus-specific genotype data. A score test for detecting haplotype-based association using genotype data has been developed in the context of generalized linear models for analysis of data from cross-sectional and retrospective studies. In this article, we develop a test for association using genotype data from cohort and nested case-control studies where subjects are prospectively followed until disease incidence or censoring (end of follow-up) occurs. Assuming a proportional hazard model for the haplotype effects, we derive an induced hazard function of the disease given the genotype data, and hence propose a test statistic based on the associated partial likelihood. The proposed test procedure can account for differential follow-up of subjects, can adjust for possibly time-dependent environmental co-factors and can make efficient use of valuable age-at-onset information that is available on cases. We provide an algorithm for computing the test statistic using readily available statistical software. Utilizing simulated data in the context of two genomic regions GPX1 and GPX3, we evaluate the validity of the proposed test for small sample sizes and study its power in the presence and absence of missing genotype data.     

Average attributable fractions: a coherent theory for apportioning excess risk to individual risk factors and subpopulations

The attributable fraction in a population and the attributable fraction in exposed are different epidemiologic measures for quantifying the contribution of a risk factor to the risk of disease. While the attributable fraction in a population depends on both the relative risk of disease and the risk of being exposed in the population, the attributable fraction in exposed depends only on the relative risk. Similar relationships apply to the combined attributable fraction in a population and in exposed, respectively, for quantifying the total contribution of a group of risk factors. Eide and Gefeller (1995) showed how the sequential and average attributable fractions could be applied to quantify the contributions of the individual risk factors to a combined attributable fraction in a population. The present paper shows how this methodology can be extended to the combined attributable fraction in exposed. The resulting average attributable fractions in exposed are compared to other proposed methods. The relationship between the average attributable fractions in a population and in exposed is outlined, thus establishing a coherent theory for apportioning attributable fractions in individuals, groups of individuals and populations, to single risk factors or groups of risk factors like modifiable versus nonmodifiable factors.     

Regression analysis of grouped survival data with application to breast cancer data

Use of the proportional hazards regression model (Cox 1972) substantially liberalized the analysis of censored survival data with covariates. Available procedures for estimation of the relative risk parameter, however, do not adequately handle grouped survival data, or large data sets with many tied failure times. The grouped data version of the proportional hazards model is proposed here for such estimation. Asymptotic likelihood results are given, both for the estimation of the regression coefficient and the survivor function. Some special results are given for testing the hypothesis of a zero regression coefficient which leads, for example, to a generalization of the log-rank test for the comparison of several survival curves. Application to breast cancer data, from the National Cancer Institute-sponsored End Results Group, indicates that previously noted race differences in breast cancer survival times are explained to a large extent by differences in disease extent and other demographic characteristics at diagnosis.     

Tree-augmented Cox proportional hazards models

We study a hybrid model that combines Cox proportional hazards regression with tree-structured modeling. The main idea is to use step functions, provided by a tree structure, to 'augment' Cox (1972) proportional hazards models. The proposed model not only provides a natural assessment of the adequacy of the Cox proportional hazards model but also improves its model fitting without loss of interpretability. Both simulations and an empirical example are provided to illustrate the use of the proposed method.     

A Multilevel Model to Estimate the Within- and the Between-Center Components of the Exposure/Disease Association in the EPIC Study

In a multicenter study, the overall relationship between exposure and the risk of cancer can be broken down into a within-center component, which reflects the individual level association, and a between-center relationship, which captures the association at the aggregate level. A piecewise exponential proportional hazards model with random effects was used to evaluate the association between dietary fiber intake and colorectal cancer (CRC) risk in the EPIC study. During an average follow-up of 11.0 years, 4,517 CRC events occurred among study participants recruited in 28 centers from ten European countries. Models were adjusted by relevant confounding factors. Heterogeneity among centers was modelled with random effects. Linear regression calibration was used to account for errors in dietary questionnaire (DQ) measurements. Risk ratio estimates for a 10 g/day increment in dietary fiber were equal to 0.90 (95%CI: 0.85, 0.96) and 0.85 (0.64, 1.14), at the individual and aggregate levels, respectively, while calibrated estimates were 0.85 (0.76, 0.94), and 0.87 (0.65, 1.15), respectively. In multicenter studies, over a straightforward ecological analysis, random effects models allow information at the individual and ecologic levels to be captured, while controlling for confounding at both levels of evidence.     

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.     

Robust combination of multiple diagnostic tests for classifying censored event times

Recent advancement in technology promises to yield a multitude of tests for disease diagnosis and prognosis. When there are multiple sources of information available, it is often of interest to construct a composite score that can provide better classification accuracy than any individual measurement. In this paper, we consider robust procedures for optimally combining tests when test results are measured prior to disease onset and disease status evolves over time. To account for censoring of disease onset time, the most commonly used approach to combining tests to detect subsequent disease status is to fit a proportional hazards model (Cox, 1972) and use the estimated risk score. However, simulation studies suggested that such a risk score may have poor accuracy when the proportional hazards assumption fails. We propose the use of a nonparametric transformation model (Han, 1987) as a working model to derive an optimal composite score with theoretical justification. We demonstrate that the proposed score is the optimal score when the model holds and is optimal "on average" among linear scores even if the model fails. Time-dependent sensitivity, specificity, and receiver operating characteristic curve functions are used to quantify the accuracy of the resulting composite score. We provide consistent and asymptotically Gaussian estimators of these accuracy measures. A simple model-free resampling procedure is proposed to obtain all consistent variance estimators. We illustrate the new proposals with simulation studies and an analysis of a breast cancer gene expression data set.     

Haplotype-based association analysis in cohort and nested case-control studies

Genetic epidemiologic studies often collect genotype data at multiple loci within a genomic region of interest from a sample of unrelated individuals. One popular method for analyzing such data is to assess whether haplotypes, i.e., the arrangements of alleles along individual chromosomes, are associated with the disease phenotype or not. For many study subjects, however, the exact haplotype configuration on the pair of homologous chromosomes cannot be derived with certainty from the available locus-specific genotype data (phase ambiguity). In this article, we consider estimating haplotype-specific association parameters in the Cox proportional hazards model, using genotype, environmental exposure, and the disease endpoint data collected from cohort or nested case-control studies. We study alternative Expectation-Maximization algorithms for estimating haplotype frequencies from cohort and nested case-control studies. Based on a hazard function of the disease derived from the observed genotype data, we then propose a semiparametric method for joint estimation of relative-risk parameters and the cumulative baseline hazard function. The method is greatly simplified under a rare disease assumption, for which an asymptotic variance estimator is also proposed. The performance of the proposed estimators is assessed via simulation studies. An application of the proposed method is presented, using data from the Alpha-Tocopherol, Beta-Carotene Cancer Prevention Study.     

"Smooth" semiparametric regression analysis for arbitrarily censored time-to-event data

Summary .   A general framework for regression analysis of time-to-event data subject to arbitrary patterns of censoring is proposed. The approach is relevant when the analyst is willing to assume that distributions governing model components that are ordinarily left unspecified in popular semiparametric regression models, such as the baseline hazard function in the proportional hazards model, have densities satisfying mild "smoothness" conditions. Densities are approximated by a truncated series expansion that, for fixed degree of truncation, results in a "parametric" representation, which makes likelihood-based inference coupled with adaptive choice of the degree of truncation, and hence flexibility of the model, computationally and conceptually straightforward with data subject to any pattern of censoring. The formulation allows popular models, such as the proportional hazards, proportional odds, and accelerated failure time models, to be placed in a common framework; provides a principled basis for choosing among them; and renders useful extensions of the models straightforward. The utility and performance of the methods are demonstrated via simulations and by application to data from time-to-event studies.     

Estimating differences in restricted mean lifetime using observational data subject to dependent censoring

In epidemiologic studies of time to an event, mean lifetime is often of direct interest. We propose methods to estimate group- (e.g., treatment-) specific differences in restricted mean lifetime for studies where treatment is not randomized and lifetimes are subject to both dependent and independent censoring. The proposed methods may be viewed as a hybrid of two general approaches to accounting for confounders. Specifically, treatment-specific proportional hazards models are employed to account for baseline covariates, while inverse probability of censoring weighting is used to accommodate time-dependent predictors of censoring. The average causal effect is then obtained by averaging over differences in fitted values based on the proportional hazards models. Large-sample properties of the proposed estimators are derived and simulation studies are conducted to assess their finite-sample applicability. We apply the proposed methods to liver wait list mortality data from the Scientific Registry of Transplant Recipients.     

Covariate analysis of viral eradication studies

An important issue arising in therapeutic studies of hepatitis C and HIV is the identification of and adjustment for covariates associated with viral eradication and resistance. Analyses of such data are complicated by the fact that eradication is an occult event that is not directly observable, resulting in unique types of censored observations that do not arise in other competing risks settings. This paper proposes a semiparametric regression model to assess the association between multiple covariates and the eradication/resistance processes. The proposed methods are based on a piecewise proportional hazards model that allows parameters to vary between observation times. We illustrate the methods with data from recent hepatitis C clinical trials.     

Bias analysis and the simulation‐extrapolation method for survival data with covariate measurement error under parametric proportional odds models

It has been well known that ignoring measurement error may result in substantially biased estimates in many contexts including linear and nonlinear regressions. For survival data with measurement error in covariates, there has been extensive discussion in the literature with the focus on proportional hazards (PH) models. Recently, research interest has extended to accelerated failure time (AFT) and additive hazards (AH) models. However, the impact of measurement error on other models, such as the proportional odds model, has received relatively little attention, although these models are important alternatives when PH, AFT, or AH models are not appropriate to fit data. In this paper, we investigate this important problem and study the bias induced by the naive approach of ignoring covariate measurement error. To adjust for the induced bias, we describe the simulation‐extrapolation method. The proposed method enjoys a number of appealing features. Its implementation is straightforward and can be accomplished with minor modifications of existing software. More importantly, the proposed method does not require modeling the covariate process, which is quite attractive in practice. As the precise values of error‐prone covariates are often not observable, any modeling assumption on such covariates has the risk of model misspecification, hence yielding invalid inferences if this happens. The proposed method is carefully assessed both theoretically and empirically. Theoretically, we establish the asymptotic normality for resulting estimators. Numerically, simulation studies are carried out to evaluate the performance of the estimators as well as the impact of ignoring measurement error, along with an application to a data set arising from the Busselton Health Study. Sensitivity of the proposed method to misspecification of the error model is studied as well.     

Multivariate survival analysis for case-control family data

Multivariate survival data arise from case-control family studies in which the ages at disease onset for family members may be correlated. In this paper, we consider a multivariate survival model with the marginal hazard function following the proportional hazards model. We use a frailty-based approach in the spirit of Glidden and Self (1999) to account for the correlation of ages at onset among family members. Specifically, we first estimate the baseline hazard function nonparametrically by the innovation theorem, and then obtain maximum pseudolikelihood estimators for the regression and correlation parameters plugging in the baseline hazard function estimator. We establish a connection with a previously proposed generalized estimating equation-based approach. Simulation studies and an analysis of case-control family data of breast cancer illustrate the methodology's practical utility.