Bayesian dose-finding in phase I/II clinical trials using toxicity and efficacy odds ratios

A Bayesian adaptive design is proposed for dose-finding in phase I/II clinical trials to incorporate the bivariate outcomes, toxicity and efficacy, of a new treatment. Without specifying any parametric functional form for the drug dose-response curve, we jointly model the bivariate binary data to account for the correlation between toxicity and efficacy. After observing all the responses of each cohort of patients, the dosage for the next cohort is escalated, deescalated, or unchanged according to the proposed odds ratio criteria constructed from the posterior toxicity and efficacy probabilities. A novel class of prior distributions is proposed through logit transformations which implicitly imposes a monotonic constraint on dose toxicity probabilities and correlates the probabilities of the bivariate outcomes. We conduct simulation studies to evaluate the operating characteristics of the proposed method. Under various scenarios, the new Bayesian design based on the toxicity-efficacy odds ratio trade-offs exhibits good properties and treats most patients at the desirable dose levels. The method is illustrated with a real trial design for a breast medical oncology study.     

Monotone spline‐based least squares estimation for panel count data with informative observation times

This article discusses the statistical analysis of panel count data when the underlying recurrent event process and observation process may be correlated. For the recurrent event process, we propose a new class of semiparametric mean models that allows for the interaction between the observation history and covariates. For inference on the model parameters, a monotone spline‐based least squares estimation approach is developed, and the resulting estimators are consistent and asymptotically normal. In particular, our new approach does not rely on the model specification of the observation process. The proposed inference procedure performs well through simulation studies, and it is illustrated by the analysis of bladder tumor data.     

Semiparametric analysis of recurrent events data in the presence of dependent censoring

Dependent censoring occurs in longitudinal studies of recurrent events when the censoring time depends on the potentially unobserved recurrent event times. To perform regression analysis in this setting, we propose a semiparametric joint model that formulates the marginal distributions of the recurrent event process and dependent censoring time through scale-change models, while leaving the distributional form and dependence structure unspecified. We derive consistent and asymptotically normal estimators for the regression parameters. We also develop graphical and numerical methods for assessing the adequacy of the proposed model. The finite-sample behavior of the new inference procedures is evaluated through simulation studies. An application to recurrent hospitalization data taken from a study of intravenous drug users is provided.     

Nonparametric analysis of recurrent events and death

This article is concerned with the analysis of recurrent events in the presence of a terminal event such as death. We consider the mean frequency function, defined as the marginal mean of the cumulative number of recurrent events over time. A simple nonparametric estimator for this quantity is presented. It is shown that the estimator, properly normalized, converges weakly to a zero-mean Gaussian process with an easily estimable covariance function. Nonparametric statistics for comparing two mean frequency functions and for combining data on recurrent events and death are also developed. The asymptotic null distributions of these statistics, together with consistent variance estimators, are derived. The small-sample properties of the proposed estimators and test statistics are examined through simulation studies. An application to a cancer clinical trial is provided.     

Bivariate Mixed Effects Analysis of Clustered Data with Large Cluster Sizes

Linear mixed effects models are widely used to analyze a clustered response variable. Motivated by a recent study to examine and compare the hospital length of stay (LOS) between patients undertaking percutaneous coronary intervention (PCI) and coronary artery bypass graft (CABG) from several international clinical trials, we proposed a bivariate linear mixed effects model for the joint modeling of clustered PCI and CABG LOSs where each clinical trial is considered a cluster. Due to the large number of patients in some trials, commonly used commercial statistical software for fitting (bivariate) linear mixed models failed to run since it could not allocate enough memory to invert large dimensional matrices during the optimization process. We consider ways to circumvent the computational problem in the maximum likelihood (ML) inference and restricted maximum likelihood (REML) inference. Particularly, we developed an expected and maximization (EM) algorithm for the REML inference and presented an ML implementation using existing software. The new REML EM algorithm is easy to implement and computationally stable and efficient. With this REML EM algorithm, we could analyze the LOS data and obtained meaningful results.     

Analysis of multivariate recurrent event data with time‐dependent covariates and informative censoring

Multivariate recurrent event data are usually encountered in many clinical and longitudinal studies in which each study subject may experience multiple recurrent events. For the analysis of such data, most existing approaches have been proposed under the assumption that the censoring times are noninformative, which may not be true especially when the observation of recurrent events is terminated by a failure event. In this article, we consider regression analysis of multivariate recurrent event data with both time‐dependent and time‐independent covariates where the censoring times and the recurrent event process are allowed to be correlated via a frailty. The proposed joint model is flexible where both the distributions of censoring and frailty variables are left unspecified. We propose a pairwise pseudolikelihood approach and an estimating equation‐based approach for estimating coefficients of time‐dependent and time‐independent covariates, respectively. The large sample properties of the proposed estimates are established, while the finite‐sample properties are demonstrated by simulation studies. The proposed methods are applied to the analysis of a set of bivariate recurrent event data from a study of platelet transfusion reactions.     

Hierarchical spatial modeling of additive and dominance genetic variance for large spatial trial datasets

Summary .  This article expands upon recent interest in Bayesian hierarchical models in quantitative genetics by developing spatial process models for inference on additive and dominance genetic variance within the context of large spatially referenced trial datasets. Direct application of such models to large spatial datasets are, however, computationally infeasible because of cubic-order matrix algorithms involved in estimation. The situation is even worse in Markov chain Monte Carlo (MCMC) contexts where such computations are performed for several iterations. Here, we discuss approaches that help obviate these hurdles without sacrificing the richness in modeling. For genetic effects, we demonstrate how an initial spectral decomposition of the relationship matrices negate the expensive matrix inversions required in previously proposed MCMC methods. For spatial effects, we outline two approaches for circumventing the prohibitively expensive matrix decompositions: the first leverages analytical results from Ornstein–Uhlenbeck processes that yield computationally efficient tridiagonal structures, whereas the second derives a modified predictive process model from the original model by projecting its realizations to a lower-dimensional subspace, thereby reducing the computational burden. We illustrate the proposed methods using a synthetic dataset with additive, dominance, genetic effects and anisotropic spatial residuals, and a large dataset from a Scots pine ( Pinus sylvestris L.) progeny study conducted in northern Sweden. Our approaches enable us to provide a comprehensive analysis of this large trial, which amply demonstrates that, in addition to violating basic assumptions of the linear model, ignoring spatial effects can result in downwardly biased measures of heritability.     

Analyzing recurrent and nonrecurrent terminal events data in discrete time

Joint analysis of recurrent and nonrecurrent terminal events has attracted substantial attention in literature. However, there lacks formal methodology for such analysis when the event time data are on discrete scales, even though some modeling and inference strategies have been developed for discrete-time survival analysis. We propose a discrete-time joint modeling approach for the analysis of recurrent and terminal events where the two types of events may be correlated with each other. The proposed joint modeling assumes a shared frailty to account for the dependence among recurrent events and between the recurrent and the terminal terminal events. Also, the joint modeling allows for time-dependent covariates and rich families of transformation models for the recurrent and terminal events. A major advantage of our approach is that it does not assume a distribution for the frailty, nor does it assume a Poisson process for the analysis of the recurrent event. The utility of the proposed analysis is illustrated by simulation studies and two real applications, where the application to the biochemists' rank promotion data jointly analyzes the biochemists' citation numbers and times to rank promotion, and the application to the scleroderma lung study data jointly analyzes the adverse events and off-drug time among patients with the symptomatic scleroderma-related interstitial lung disease.     

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.     

Bayesian nonparametric analysis of restricted mean survival time

The restricted mean survival time (RMST) evaluates the expectation of survival time truncated by a prespecified time point, because the mean survival time in the presence of censoring is typically not estimable. The frequentist inference procedure for RMST has been widely advocated for comparison of two survival curves, while research from the Bayesian perspective is rather limited. For the RMST of both right- and interval-censored data, we propose Bayesian nonparametric estimation and inference procedures. By assigning a mixture of Dirichlet processes (MDP) prior to the distribution function, we can estimate the posterior distribution of RMST. We also explore another Bayesian nonparametric approach using the Dirichlet process mixture model and make comparisons with the frequentist nonparametric method. Simulation studies demonstrate that the Bayesian nonparametric RMST under diffuse MDP priors leads to robust estimation and under informative priors it can incorporate prior knowledge into the nonparametric estimator. Analysis of real trial examples demonstrates the flexibility and interpretability of the Bayesian nonparametric RMST for both right- and interval-censored data.     

Bayesian Semiparametric Models for Survival Data with a Cure Fraction

We propose methods for Bayesian inference for a new class of semiparametric survival models with a cure fraction. Specifically, we propose a semiparametric cure rate model with a smoothing parameter that controls the degree of parametricity in the right tail of the survival distribution. We show that such a parameter is crucial for these kinds of models and can have an impact on the posterior estimates. Several novel properties of the proposed model are derived. In addition, we propose a class of improper noninformative priors based on this model and examine the properties of the implied posterior. Also, a class of informative priors based on historical data is proposed and its theoretical properties are investigated. A case study involving a melanoma clinical trial is discussed in detail to demonstrate the proposed methodology.     

Semiparametric frailty models for zero‐inflated event count data in the presence of informative dropout

Recurrent events data are commonly encountered in medical studies. In many applications, only the number of events during the follow‐up period rather than the recurrent event times is available. Two important challenges arise in such studies: (a) a substantial portion of subjects may not experience the event, and (b) we may not observe the event count for the entire study period due to informative dropout. To address the first challenge, we assume that underlying population consists of two subpopulations: a subpopulation nonsusceptible to the event of interest and a subpopulation susceptible to the event of interest. In the susceptible subpopulation, the event count is assumed to follow a Poisson distribution given the follow‐up time and the subject‐specific characteristics. We then introduce a frailty to account for informative dropout. The proposed semiparametric frailty models consist of three submodels: (a) a logistic regression model for the probability such that a subject belongs to the nonsusceptible subpopulation; (b) a nonhomogeneous Poisson process model with an unspecified baseline rate function; and (c) a Cox model for the informative dropout time. We develop likelihood‐based estimation and inference procedures. The maximum likelihood estimators are shown to be consistent. Additionally, the proposed estimators of the finite‐dimensional parameters are asymptotically normal and the covariance matrix attains the semiparametric efficiency bound. Simulation studies demonstrate that the proposed methodologies perform well in practical situations. We apply the proposed methods to a clinical trial on patients with myelodysplastic syndromes.     

A Bayesian approach for the analysis of panel-count data with dependent termination

We consider modeling and Bayesian analysis for panel-count data when the termination time for each subject may depend on its history of the recurrent events. We propose a fully specified semiparametric model for the joint distribution of the recurrent events and the termination time. For this model, we provide a natural motivation, derive several novel properties, and develop a Bayesian analysis based on a Markov chain Monte Carlo algorithm. Comparisons are made to other existing models and methods for panel-count data. We demonstrate the usefulness of our new models and methodologies through the reanalysis of a data set from a clinical trial.     

Bayesian semiparametric dynamic frailty models for multiple event time data

Many biomedical studies collect data on times of occurrence for a health event that can occur repeatedly, such as infection, hospitalization, recurrence of disease, or tumor onset. To analyze such data, it is necessary to account for within-subject dependency in the multiple event times. Motivated by data from studies of palpable tumors, this article proposes a dynamic frailty model and Bayesian semiparametric approach to inference. The widely used shared frailty proportional hazards model is generalized to allow subject-specific frailties to change dynamically with age while also accommodating nonproportional hazards. Parametric assumptions on the frailty distribution are avoided by using Dirichlet process priors for a shared frailty and for multiplicative innovations on this frailty. By centering the semiparametric model on a conditionally conjugate dynamic gamma model, we facilitate posterior computation and lack-of-fit assessments of the parametric model. Our proposed method is demonstrated using data from a cancer chemoprevention study.     

Bayesian semiparametric intensity estimation for inhomogeneous spatial point processes

In this work we propose a fully Bayesian semiparametric method to estimate the intensity of an inhomogeneous spatial point process. The basic idea is to first convert intensity estimation into a Poisson regression setting via binning data points on a regular grid, and then model the log intensity semiparametrically using an adaptive version of Gaussian Markov random fields to smooth the corresponding counts. The inference is carried by an efficient Markov chain Monte Carlo simulation algorithm. Compared to existing methods for intensity estimation, for example, parametric modeling and kernel smoothing, the proposed estimator not only provides inference regarding the dependence of the intensity function on possible covariates, but also uses information from the data to adaptively determine the amount of smoothing at the local level. The effectiveness of using our method is demonstrated through simulation studies and an application to a rainforest dataset.     

Joint monitoring and prediction of accrual and event times in clinical trials

In many clinical trials, the primary endpoint is time to an event of interest, for example, time to cardiac attack or tumor progression, and the statistical power of these trials is primarily driven by the number of events observed during the trials. In such trials, the number of events observed is impacted not only by the number of subjects enrolled but also by other factors including the event rate and the follow‐up duration. Consequently, it is important for investigators to be able to monitor and predict accurately patient accrual and event times so as to predict the times of interim and final analyses and enable efficient allocation of research resources, which have long been recognized as important aspects of trial design and conduct. The existing methods for prediction of event times all assume that patient accrual follows a Poisson process with a constant Poisson rate over time; however, it is fairly common in real‐life clinical trials that the Poisson rate changes over time. In this paper, we propose a Bayesian joint modeling approach for monitoring and prediction of accrual and event times in clinical trials. We employ a nonhomogeneous Poisson process to model patient accrual and a parametric or nonparametric model for the event and loss to follow‐up processes. Compared to existing methods, our proposed methods are more flexible and robust in that we model accrual and event/loss‐to‐follow‐up times jointly and allow the underlying accrual rates to change over time. We evaluate the performance of the proposed methods through simulation studies and illustrate the methods using data from a real oncology trial.     

Risk‐Group‐Specific Dose Finding Based on an Average Toxicity Score

Summary We propose a Bayesian dose‐finding design that accounts for two important factors, the severity of toxicity and heterogeneity in patients' susceptibility to toxicity. We consider toxicity outcomes with various levels of severity and define appropriate scores for these severity levels. We then use a multinomial‐likelihood function and a Dirichlet prior to model the probabilities of these toxicity scores at each dose, and characterize the overall toxicity using an average toxicity score (ATS) parameter. To address the issue of heterogeneity in patients' susceptibility to toxicity, we categorize patients into different risk groups based on their susceptibility. A Bayesian isotonic transformation is applied to induce an order‐restricted posterior inference on the ATS. We demonstrate the performance of the proposed dose‐finding design using simulations based on a clinical trial in multiple myeloma.     

Bayesian Inference in Semiparametric Mixed Models for Longitudinal Data

Summary .  We consider Bayesian inference in semiparametric mixed models (SPMMs) for longitudinal data. SPMMs are a class of models that use a nonparametric function to model a time effect, a parametric function to model other covariate effects, and parametric or nonparametric random effects to account for the within-subject correlation. We model the nonparametric function using a Bayesian formulation of a cubic smoothing spline, and the random effect distribution using a normal distribution and alternatively a nonparametric Dirichlet process (DP) prior. When the random effect distribution is assumed to be normal, we propose a uniform shrinkage prior (USP) for the variance components and the smoothing parameter. When the random effect distribution is modeled nonparametrically, we use a DP prior with a normal base measure and propose a USP for the hyperparameters of the DP base measure. We argue that the commonly assumed DP prior implies a nonzero mean of the random effect distribution, even when a base measure with mean zero is specified. This implies weak identifiability for the fixed effects, and can therefore lead to biased estimators and poor inference for the regression coefficients and the spline estimator of the nonparametric function. We propose an adjustment using a postprocessing technique. We show that under mild conditions the posterior is proper under the proposed USP, a flat prior for the fixed effect parameters, and an improper prior for the residual variance. We illustrate the proposed approach using a longitudinal hormone dataset, and carry out extensive simulation studies to compare its finite sample performance with existing methods.     

A model checking method for the proportional hazards model with recurrent gap time data

Recurrent events are the natural outcome in many medical and epidemiology studies. To assess covariate effects on the gaps between consecutive recurrent events, the Cox proportional hazards model is frequently employed in data analysis. The validity of statistical inference, however, depends on the appropriateness of the Cox model. In this paper, we propose a class of graphical techniques and formal tests for checking the Cox model with recurrent gap time data. The building block of our model checking method is an averaged martingale-like process, based on which a class of multiparameter stochastic processes is proposed. This maneuver is very general and can be used to assess different aspects of model fit. Numerical simulations are conducted to examine finite-sample performance, and the proposed model checking techniques are illustrated with data from the Danish Psychiatric Central Register.