Estimation in the cox proportional hazards model with left-truncated and interval-censored data

We show that the nonparametric maximum likelihood estimate (NPMLE) of the regression coefficient from the joint likelihood (of the regression coefficient and the baseline survival) works well for the Cox proportional hazards model with left-truncated and interval-censored data, but the NPMLE may underestimate the baseline survival. Two alternatives are also considered: first, the marginal likelihood approach by extending Satten (1996, Biometrika 83, 355-370) to truncated data, where the baseline distribution is eliminated as a nuisance parameter; and second, the monotone maximum likelihood estimate that maximizes the joint likelihood by assuming that the baseline distribution has a nondecreasing hazard function, which was originally proposed to overcome the underestimation of the survival from the NPMLE for left-truncated data without covariates (Tsai, 1988, Biometrika 75, 319-324). The bootstrap is proposed to draw inference. Simulations were conducted to assess their performance. The methods are applied to the Massachusetts Health Care Panel Study data set to compare the probabilities of losing functional independence for male and female seniors.     

Dimension reduction for integrative survival analysis

We propose a constrained maximum partial likelihood estimator for dimension reduction in integrative (e.g., pan-cancer) survival analysis with high-dimensional predictors. We assume that for each population in the study, the hazard function follows a distinct Cox proportional hazards model. To borrow information across populations, we assume that each of the hazard functions depend only on a small number of linear combinations of the predictors (i.e., “factors”). We estimate these linear combinations using an algorithm based on “distance-to-set” penalties. This allows us to impose both low-rankness and sparsity on the regression coefficient matrix estimator. We derive asymptotic results that reveal that our estimator is more efficient than fitting a separate proportional hazards model for each population. Numerical experiments suggest that our method outperforms competitors under various data generating models. We use our method to perform a pan-cancer survival analysis relating protein expression to survival across 18 distinct cancer types. Our approach identifies six linear combinations, depending on only 20 proteins, which explain survival across the cancer types. Finally, to validate our fitted model, we show that our estimated factors can lead to better prediction than competitors on four external datasets.     

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.     

Statistical analysis of survival data from radiation countermeasure experiments

We present an introduction to, and examples of, Cox proportional hazards regression in the context of animal lethality studies of potential radioprotective agents. This established method is seldom used to analyze survival data collected in such studies, but is appropriate in many instances. Presenting a hypothetical radiation study that examines the efficacy of a potential radioprotectant both in the absence and presence of a potential modifier, we detail how to implement and interpret results from a Cox proportional hazards regression analysis used to analyze the survival data, and we provide relevant SAS? code. Cox proportional hazards regression analysis of survival data from lethal radiation experiments (1) considers the whole distribution of survival times rather than simply the commonly used proportions of animals that survived, (2) provides a unified analysis when multiple factors are present, and (3) can increase statistical power by combining information across different levels of a factor. Cox proportional hazards regression should be considered as a potential statistical method in the toolbox of radiation researchers.     

A semiparametric estimate of treatment effects with censored data

A semiparametric estimate of an average regression effect with right-censored failure time data has recently been proposed under the Cox-type model where the regression effect beta(t) is allowed to vary with time. In this article, we derive a simple algebraic relationship between this average regression effect and a measurement of group differences in k-sample transformation models when the random error belongs to the G(rho) family of Harrington and Fleming (1982, Biometrika 69, 553-566), the latter being equivalent to the conditional regression effect in a gamma frailty model. The models considered here are suitable for the attenuating hazard ratios that often arise in practice. The results reveal an interesting connection among the above three classes of models as alternatives to the proportional hazards assumption and add to our understanding of the behavior of the partial likelihood estimate under nonproportional hazards. The algebraic relationship provides a simple estimator under the transformation model. We develop a variance estimator based on the empirical influence function that is much easier to compute than the previously suggested resampling methods. When there is truncation in the right tail of the failure times, we propose a method of bias correction to improve the coverage properties of the confidence intervals. The estimate, its estimated variance, and the bias correction term can all be calculated with minor modifications to standard software for proportional hazards regression.     

A nonparametric mixture model for cure rate estimation

Nonparametric methods have attracted less attention than their parametric counterparts for cure rate analysis. In this paper, we study a general nonparametric mixture model. The proportional hazards assumption is employed in modeling the effect of covariates on the failure time of patients who are not cured. The EM algorithm, the marginal likelihood approach, and multiple imputations are employed to estimate parameters of interest in the model. This model extends models and improves estimation methods proposed by other researchers. It also extends Cox's proportional hazards regression model by allowing a proportion of event-free patients and investigating covariate effects on that proportion. The model and its estimation method are investigated by simulations. An application to breast cancer data, including comparisons with previous analyses using a parametric model and an existing nonparametric model by other researchers, confirms the conclusions from the parametric model but not those from the existing nonparametric model.     

A simple linear regression method for quantitative trait loci linkage analysis with censored observations

Standard quantitative trait loci (QTL) mapping techniques commonly assume that the trait is both fully observed and normally distributed. When considering survival or age-at-onset traits these assumptions are often incorrect. Methods have been developed to map QTL for survival traits; however, they are both computationally intensive and not available in standard genome analysis software packages. We propose a grouped linear regression method for the analysis of continuous survival data. Using simulation we compare this method to both the Cox and Weibull proportional hazards models and a standard linear regression method that ignores censoring. The grouped linear regression method is of equivalent power to both the Cox and Weibull proportional hazards methods and is significantly better than the standard linear regression method when censored observations are present. The method is also robust to the proportion of censored individuals and the underlying distribution of the trait. On the basis of linear regression methodology, the grouped linear regression model is computationally simple and fast and can be implemented readily in freely available statistical software.     

Joint modeling of survival and longitudinal data: likelihood approach revisited

The maximum likelihood approach to jointly model the survival time and its longitudinal covariates has been successful to model both processes in longitudinal studies. Random effects in the longitudinal process are often used to model the survival times through a proportional hazards model, and this invokes an EM algorithm to search for the maximum likelihood estimates (MLEs). Several intriguing issues are examined here, including the robustness of the MLEs against departure from the normal random effects assumption, and difficulties with the profile likelihood approach to provide reliable estimates for the standard error of the MLEs. We provide insights into the robustness property and suggest to overcome the difficulty of reliable estimates for the standard errors by using bootstrap procedures. Numerical studies and data analysis illustrate our points.     

A joint model for longitudinal measurements and survival data in the presence of multiple failure types

Summary .   In this article we study a joint model for longitudinal measurements and competing risks survival data. Our joint model provides a flexible approach to handle possible nonignorable missing data in the longitudinal measurements due to dropout. It is also an extension of previous joint models with a single failure type, offering a possible way to model informatively censored events as a competing risk. Our model consists of a linear mixed effects submodel for the longitudinal outcome and a proportional cause-specific hazards frailty submodel ( Prentice et al., 1978 , Biometrics 34, 541–554) for the competing risks survival data, linked together by some latent random effects. We propose to obtain the maximum likelihood estimates of the parameters by an expectation maximization (EM) algorithm and estimate their standard errors using a profile likelihood method. The developed method works well in our simulation studies and is applied to a clinical trial for the scleroderma lung disease.     

Regression survival analysis with an assumed copula for dependent censoring: a sensitivity analysis approach

SUMMARY: In clinical studies, when censoring is caused by competing risks or patient withdrawal, there is always a concern about the validity of treatment effect estimates that are obtained under the assumption of independent censoring. Because dependent censoring is nonidentifiable without additional information, the best we can do is a sensitivity analysis to assess the changes of parameter estimates under different assumptions about the association between failure and censoring. This analysis is especially useful when knowledge about such association is available through literature review or expert opinions. In a regression analysis setting, the consequences of falsely assuming independent censoring on parameter estimates are not clear. Neither the direction nor the magnitude of the potential bias can be easily predicted. We provide an approach to do sensitivity analysis for the widely used Cox proportional hazards models. The joint distribution of the failure and censoring times is assumed to be a function of their marginal distributions. This function is called a copula. Under this assumption, we propose an iteration algorithm to estimate the regression parameters and marginal survival functions. Simulation studies show that this algorithm works well. We apply the proposed sensitivity analysis approach to the data from an AIDS clinical trial in which 27% of the patients withdrew due to toxicity or at the request of the patient or investigator.     

A Monte Carlo maximum likelihood method for estimating uncertainty arising from shared errors in exposures in epidemiological studies of nuclear workers

Errors in the estimation of exposures or doses are a major source of uncertainty in epidemiological studies of cancer among nuclear workers. This paper presents a Monte Carlo maximum likelihood method that can be used for estimating a confidence interval that reflects both statistical sampling error and uncertainty in the measurement of exposures. The method is illustrated by application to an analysis of all cancer (excluding leukemia) mortality in a study of nuclear workers at the Oak Ridge National Laboratory (ORNL). Monte Carlo methods were used to generate 10,000 data sets with a simulated corrected dose estimate for each member of the cohort based on the estimated distribution of errors in doses. A Cox proportional hazards model was applied to each of these simulated data sets. A partial likelihood, averaged over all of the simulations, was generated; the central risk estimate and confidence interval were estimated from this partial likelihood. The conventional unsimulated analysis of the ORNL study yielded an excess relative risk (ERR) of 5.38 per Sv (90% confidence interval 0.54-12.58). The Monte Carlo maximum likelihood method yielded a slightly lower ERR (4.82 per Sv) and wider confidence interval (0.41-13.31).     

Fitting semiparametric additive hazards models using standard statistical software

The Cox proportional hazards model has become the standard in biomedical studies, particularly for settings in which the estimation covariate effects (as opposed to prediction) is the primary objective. In spite of the obvious flexibility of this approach and its wide applicability, the model is not usually chosen for its fit to the data, but by convention and for reasons of convenience. It is quite possible that the covariates add to, rather than multiply the baseline hazard, making an additive hazards model a more suitable choice. Typically, proportionality is assumed, with the potential for additive covariate effects not evaluated or even seriously considered. Contributing to this phenomenon is the fact that many popular software packages (e.g., SAS, S-PLUS/R) have standard procedures to fit the Cox model (e.g., proc phreg, coxph), but as of yet no analogous procedures to fit its additive analog, the Lin and Ying (1994) semiparametric additive hazards model. In this article, we establish the connections between the Lin and Ying (1994) model and both Cox and least squares regression. We demonstrate how SAS's phreg and reg procedures may be used to fit the additive hazards model, after some straightforward data manipulations. We then apply the additive hazards model to examine the relationship between Model for End-stage Liver Disease (MELD) score and mortality among patients wait-listed for liver transplantation.     

A multiple imputation approach to Cox regression with interval-censored data

We propose a general semiparametric method based on multiple imputation for Cox regression with interval-censored data. The method consists of iterating the following two steps. First, from finite-interval-censored (but not right-censored) data, exact failure times are imputed using Tanner and Wei's poor man's or asymptotic normal data augmentation scheme based on the current estimates of the regression coefficient and the baseline survival curve. Second, a standard statistical procedure for right-censored data, such as the Cox partial likelihood method, is applied to imputed data to update the estimates. Through simulation, we demonstrate that the resulting estimate of the regression coefficient and its associated standard error provide a promising alternative to the nonparametric maximum likelihood estimate. Our proposal is easily implemented by taking advantage of existing computer programs for right-censored data.     

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.     

Joint Analysis of Survival Time and Longitudinal Categorical Outcomes

In biomedical or public health research, it is common for both survival time and longitudinal categorical outcomes to be collected for a subject, along with the subject’s characteristics or risk factors. Investigators are often interested in finding important variables for predicting both survival time and longitudinal outcomes which could be correlated within the same subject. Existing approaches for such joint analyses deal with continuous longitudinal outcomes. New statistical methods need to be developed for categorical longitudinal outcomes. We propose to simultaneously model the survival time with a stratified Cox proportional hazards model and the longitudinal categorical outcomes with a generalized linear mixed model. Random effects are introduced to account for the dependence between survival time and longitudinal outcomes due to unobserved factors. The Expectation–Maximization (EM) algorithm is used to derive the point estimates for the model parameters, and the observed information matrix is adopted to estimate their asymptotic variances. Asymptotic properties for our proposed maximum likelihood estimators are established using the theory of empirical processes. The method is demonstrated to perform well in finite samples via simulation studies. We illustrate our approach with data from the Carolina Head and Neck Cancer Study (CHANCE) and compare the results based on our simultaneous analysis and the separately conducted analyses using the generalized linear mixed model and the Cox proportional hazards model. Our proposed method identifies more predictors than by separate analyses.     

Estimation in a Cox proportional hazards cure model

Some failure time data come from a population that consists of some subjects who are susceptible to and others who are nonsusceptible to the event of interest. The data typically have heavy censoring at the end of the follow-up period, and a standard survival analysis would not always be appropriate. In such situations where there is good scientific or empirical evidence of a nonsusceptible population, the mixture or cure model can be used (Farewell, 1982, Biometrics 38, 1041-1046). It assumes a binary distribution to model the incidence probability and a parametric failure time distribution to model the latency. Kuk and Chen (1992, Biometrika 79, 531-541) extended the model by using Cox's proportional hazards regression for the latency. We develop maximum likelihood techniques for the joint estimation of the incidence and latency regression parameters in this model using the nonparametric form of the likelihood and an EM algorithm. A zero-tail constraint is used to reduce the near nonidentifiability of the problem. The inverse of the observed information matrix is used to compute the standard errors. A simulation study shows that the methods are competitive to the parametric methods under ideal conditions and are generally better when censoring from loss to follow-up is heavy. The methods are applied to a data set of tonsil cancer patients treated with radiation therapy.     

Cause‐Specific Cumulative Incidence Estimation and the Fine and Gray Model Under Both Left Truncation and Right Censoring

Summary The standard estimator for the cause‐specific cumulative incidence function in a competing risks setting with left truncated and/or right censored data can be written in two alternative forms. One is a weighted empirical cumulative distribution function and the other a product‐limit estimator. This equivalence suggests an alternative view of the analysis of time‐to‐event data with left truncation and right censoring: individuals who are still at risk or experienced an earlier competing event receive weights from the censoring and truncation mechanisms. As a consequence, inference on the cumulative scale can be performed using weighted versions of standard procedures. This holds for estimation of the cause‐specific cumulative incidence function as well as for estimation of the regression parameters in the Fine and Gray proportional subdistribution hazards model. We show that, with the appropriate filtration, a martingale property holds that allows deriving asymptotic results for the proportional subdistribution hazards model in the same way as for the standard Cox proportional hazards model. Estimation of the cause‐specific cumulative incidence function and regression on the subdistribution hazard can be performed using standard software for survival analysis if the software allows for inclusion of time‐dependent weights. We show the implementation in the R statistical package. The proportional subdistribution hazards model is used to investigate the effect of calendar period as a deterministic external time varying covariate, which can be seen as a special case of left truncation, on AIDS related and non‐AIDS related cumulative mortality.     

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.     

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 .     

Survival estimation using splines

A nonparametric maximum likelihood procedure is given for estimating the survivor function from right-censored data. It approximates the hazard rate by a simple function such as a spline, with different approximations yielding different estimators. A special case is that proposed by Nelson (1969, Journal of Quality Technology 1, 27-52) and Altshuler (1970, Mathematical Biosciences 6, 1-11). The estimators are uniformly consistent and have the same asymptotic weak convergence properties as the Kaplan-Meier (1958, Journal of the American Statistical Association 53, 457-481) estimator. However, in small and in heavily censored samples, the simplest spline estimators have uniformly smaller mean squared error than do the Kaplan-Meier and Nelson-Altshuler estimators. The procedure is extended to estimate the baseline hazard rate and regression coefficients in the Cox (1972, Journal of the Royal Statistical Society, Series B 34, 187-220) proportional hazards model and is illustrated using experimental carcinogenesis data.