Sequential covariate-adjusted randomization via hierarchically minimizing Mahalanobis distance and marginal imbalance.

In comparative studies, covariate balance and sequential allocation schemes have attracted growing academic interest. Although many theoretically justified adaptive randomization methods achieve the covariate balance, they often allocate patients in pairs or groups. To better meet the practical requirements where the clinicians cannot wait for other participants to assign the current patient for some economic or ethical reasons, we propose a method that randomizes patients individually and sequentially. The proposed method conceptually separates the covariate imbalance, measured by the newly proposed modified Mahalanobis distance, and the marginal imbalance, that is the sample size difference between the 2 groups, and it minimizes them with an explicit priority order. Compared with the existing sequential randomization methods, the proposed method achieves the best possible covariate balance while maintaining the marginal balance directly, offering us more control of the randomization process. We demonstrate the superior performance of the proposed method through a wide range of simulation studies and real data analysis, and also establish theoretical guarantees for the proposed method in terms of both the convergence of the imbalance measure and the subsequent treatment effect estimation.

Robustness of response-adaptive randomization.

Doubly adaptive biased coin design (DBCD), a response-adaptive randomization scheme, aims to skew subject assignment probabilities based on accrued responses for ethical considerations. Recent years have seen substantial advances in understanding DBCD's theoretical properties, assuming correct model specification for the responses. However, concerns have been raised about the impact of model misspecification on its design and analysis. In this paper, we assess the robustness to both design model misspecification and analysis model misspecification under DBCD. On one hand, we confirm that the consistency and asymptotic normality of the allocation proportions can be preserved, even when the responses follow a distribution other than the one imposed by the design model during the implementation of DBCD. On the other hand, we extensively investigate three commonly used linear regression models for estimating and inferring the treatment effect, namely difference-in-means, analysis of covariance (ANCOVA) I, and ANCOVA II. By allowing these regression models to be arbitrarily misspecified, thereby not reflecting the true data generating process, we derive the consistency and asymptotic normality of the treatment effect estimators evaluated from the three models. The asymptotic properties show that the ANCOVA II model, which takes covariate-by-treatment interaction terms into account, yields the most efficient estimator. These results can provide theoretical support for using DBCD in scenarios involving model misspecification, thereby promoting the widespread application of this randomization procedure.

Multi-arm covariate-adaptive randomization.

Simultaneously investigating multiple treatments in a single study achieves considerable efficiency in contrast to the traditional two-arm trials. Balancing treatment allocation for influential covariates has become increasingly important in today's clinical trials. The multi-arm covariate-adaptive randomized clinical trial is one of the most powerful tools to incorporate covariate information and multiple treatments in a single study. Pocock and Simon's procedure has been extended to the multi-arm case. However, the theoretical properties of multi-arm covariate-adaptive randomization have remained largely elusive for decades. In this paper, we propose a general framework for multi-arm covariate-adaptive designs which also includes the two-arm case, and establish the corresponding theory under widely satisfied conditions. The theoretical results provide new insights into the balance properties of covariate-adaptive randomization procedures and make foundations for most existing statistical inferences under two-arm covariate-adaptive randomization. Furthermore, these open a door to study the theoretical properties of statistical inferences for clinical trials based on multi-arm covariate-adaptive randomization procedures.

Response-adaptive treatment randomization for multiple comparisons of treatments with recurrent event responses.

Recurrent event responses are frequently encountered during clinical trials of treatments for certain diseases, such as asthma. The recurrence rates of different treatments are often compared by applying the negative binomial model. In addition, a balanced treatment-allocation procedure that assigns the same number of patients to each treatment is often applied. Recently, a response-adaptive treatment-allocation procedure has been developed for trials with recurrent event data, and has been shown to be superior to balanced treatment allocation. However, this response-adaptive treatment allocation procedure is only applicable for the comparison of two treatments. In this paper, we derive response-adaptive treatment-allocation procedures for trials which comprise several treatments. As pairwise comparisons and multiple comparisons with a control are two common multiple-testing scenarios in trials with more than two treatments, corresponding treatment-allocation procedures for these scenarios are also investigated. The redesign of two clinical studies illustrates the clinical benefits that would be obtained from our proposed response-adaptive treatment-allocation procedures.

Sample size re-estimation for response-adaptive randomized clinical trials.

Clinical trials usually take a period of time to recruit volunteers, and they become a steady accumulation of data. Traditionally, the sample size of a trial is determined in advance and data is collected before analysis proceeds. Over the past decades, many strategies have been proposed and rigorous theoretical groundings have been provided to conduct sample size re-estimation. However, the application of these methodologies has not been well extended to take care of trials with adaptive designs. Therefore, we aim to fill the gap by proposing a sample size re-estimation procedure on response-adaptive randomized trial. For ethical and economical concerns, we use multiple stopping criteria with the allowance of early termination. Statistical inference is studied for the hypothesis testing under doubly-adaptive biased coin design. We also prove that the test statistics for each stage are asymptotic independently normally distributed, though dependency exists between the two stages. We find that under our methods, compared to fixed sample size design and other commonly used randomization procedures: (1) power is increased for all scenarios with adjusted sample size; (2) sample size is reduced up to 40% when underestimating the treatment effect; (3) the duration of trials is shortened. These advantages are evidenced by numerical studies and real examples.

Incorporating covariates information in adaptive clinical trials for precision medicine.

Precision medicine is the systematic use of information that pertains to an individual patient to select or optimize that patient's preventative and therapeutic care. Recent studies have classified biomarkers into predictive and prognostic biomarkers based on their roles in clinical studies. To design a clinical trial for precision medicine, predictive biomarkers and prognostic biomarkers should both be included. In statistical analysis, biomarkers are mathematically treated as covariates. We first classify covariates into predictive and prognostic covariates according to their roles. We then provide a brief review of recent advances in adaptive designs that incorporate covariates. However, the literature includes no designs that incorporate both prognostic covariates and predictive covariates simultaneously. In this paper, we propose a new family of covariate-adjusted response-adaptive (CARA) designs that incorporate both prognostic and predictive covariates and the responses. It is important to note that the predictive biomarkers and prognostic biomarkers play different roles in the new designs. The advantages of the proposed methods are demonstrated via numerical studies, and some further statistical issues are also discussed.

Testing for treatment effect in covariate-adaptive randomized trials with generalized linear models and omitted covariates.

Concerns have been expressed over the validity of statistical inference under covariate-adaptive randomization despite the extensive use in clinical trials. In the literature, the inferential properties under covariate-adaptive randomization have been mainly studied for continuous responses; in particular, it is well known that the usual two-sample t-test for treatment effect is typically conservative. This phenomenon of invalid tests has also been found for generalized linear models without adjusting for the covariates and are sometimes more worrisome due to inflated Type I error. The purpose of this study is to examine the unadjusted test for treatment effect under generalized linear models and covariate-adaptive randomization. For a large class of covariate-adaptive randomization methods, we obtain the asymptotic distribution of the test statistic under the null hypothesis and derive the conditions under which the test is conservative, valid, or anti-conservative. Several commonly used generalized linear models, such as logistic regression and Poisson regression, are discussed in detail. An adjustment method is also proposed to achieve a valid size based on the asymptotic results. Numerical studies confirm the theoretical findings and demonstrate the effectiveness of the proposed adjustment method.

Sample size re-estimation for covariate-adaptive randomized clinical trials.

Covariate-adaptive randomization (CAR) procedures have been developed in clinical trials to mitigate the imbalance of treatments among covariates. In recent years, an increasing number of trials have started to use CAR for the advantages in statistical efficiency and enhancing credibility. At the same time, sample size re-estimation (SSR) has become a common technique in industry to reduce time and cost while maintaining a good probability of success. Despite the widespread popularity of combining CAR designs with SSR, few researchers have investigated this combination theoretically. More importantly, the existing statistical inference must be adjusted to protect the desired type I error rate when a model that omits some covariates is used. In this article, we give a framework for the application of SSR in CAR trials and study the underlying theoretical properties. We give the adjusted test statistic and derive the sample size calculation formula under the CAR setting. We can tackle the difficulties caused by the adaptive features in CAR and prove the asymptotic independence between stages. Numerical studies are conducted under multiple parameter settings and scenarios that are commonly encountered in practice. The results show that all advantages of CAR and SSR can be preserved and further improved in terms of power and sample size.

Adaptive treatment allocation for comparative clinical studies with recurrent events data.

In long-term clinical studies, recurrent event data are sometimes collected and used to contrast the efficacies of two different treatments. The event reoccurrence rates can be compared using the popular negative binomial model, which incorporates information related to patient heterogeneity into a data analysis. For treatment allocation, a balanced approach in which equal sample sizes are obtained for both treatments is predominately adopted. However, if one treatment is superior, then it may be desirable to allocate fewer subjects to the less-effective treatment. To accommodate this objective, a sequential response-adaptive treatment allocation procedure is derived based on the doubly adaptive biased coin design. Our proposed treatment allocation schemes have been shown to be capable of reducing the number of subjects receiving the inferior treatment while simultaneously retaining a test power level that is comparable to that of a balanced design. The redesign of a clinical study illustrates the advantages of using our procedure.

Response adaptive randomization procedures in seamless phase II/III clinical trials.

It is desirable to work efficiently and cost effectively to evaluate new therapies in a time-sensitive and ethical manner without compromising the integrity and validity of the development process. The seamless phase II/III clinical trial has been proposed to meet this need, and its efficient, ethical and economic advantages can be strengthened by its combination with innovative response adaptive randomization (RAR) procedures. In particular, well-designed frequentist RAR procedures can target theoretically optimal allocation proportions, and there are explicit asymptotic results. However, there has been little research into seamless phase II/III clinical trials with frequentist RAR because of the difficulty in performing valid statistical inference and controlling the type I error rate. In this paper, we propose the framework for a family of frequentist RAR designs for seamless phase II/III trials, derive the asymptotic distribution of the parameter estimators using martingale processes and offer solutions to control the type I error rate. The numerical studies demonstrate our theoretical findings and the advantages of the proposed methods.

Testing hypotheses under adaptive randomization with continuous covariates in clinical trials.

Covariate-adaptive designs are widely used to balance covariates and maintain randomization in clinical trials. Adaptive designs for discrete covariates and their asymptotic properties have been well studied in the literature. However, important continuous covariates are often involved in clinical studies. Simply discretizing or categorizing continuous covariates can result in loss of information. The current understanding of adaptive designs with continuous covariates lacks a theoretical foundation as the existing works are entirely based on simulations. Consequently, conventional hypothesis testing in clinical trials using continuous covariates is still not well understood. In this paper, we establish a theoretical framework for hypothesis testing on adaptive designs with continuous covariates based on linear models. For testing treatment effects and significance of covariates, we obtain the asymptotic distributions of the test statistic under null and alternative hypotheses. Simulation studies are conducted under a class of covariate-adaptive designs, including the p-value-based method, the Su's percentile method, the empirical cumulative-distribution method, the Kullback-Leibler divergence method, and the kernel-density method. Key findings about adaptive designs with independent covariates based on linear models are (1) hypothesis testing that compares treatment effects are conservative in terms of smaller type I error, (2) hypothesis testing using adaptive designs outperforms complete randomization method in terms of power, and (3) testing on significance of covariates is still valid.

Two-way partial AUC and its properties.

Simultaneous control on true positive rate and false positive rate is of significant importance in the performance evaluation of diagnostic tests. Most of the established literature utilizes partial area under receiver operating characteristic (ROC) curve with restrictions only on false positive rate (FPR), called FPR pAUC, as a performance measure. However, its indirect control on true positive rate (TPR) is conceptually and practically misleading. In this paper, a novel and intuitive performance measure, named as two-way pAUC, is proposed, which directly quantifies partial area under ROC curve with explicit restrictions on both TPR and FPR. To estimate two-way pAUC, we devise a nonparametric estimator. Based on the estimator, a bootstrap-assisted testing method for two-way pAUC comparison is established. Moreover, to evaluate possible covariate effects on two-way pAUC, a regression analysis framework is constructed. Asymptotic normalities of the methods are provided. Advantages of the proposed methods are illustrated by simulation and Wisconsin Breast Cancer Data. We encode the methods as a publicly available R package tpAUC.

Nonparametric response-adaptive randomization for continuous responses.

Many response-adaptive randomization procedures have been proposed and studied over the past few decades. However, most of these procedures are based on parametric structure and do not directly apply to nonparametric models. In this paper, we propose a response-adaptive randomization procedure based on Mann-Whitney U test statistic. Under widely satisfied conditions, we derive asymptotic properties of the randomization procedure and further obtain power functions in form under Mann-Whitney U test. Simulations show the proposed procedure is more robust and more ethical than classical response-adaptive randomization procedures in some circumstances. Advantages of the procedure are also illustrated in a redesigned real clinical trial.

Adaptive Designs for Non-inferiority Trials with Multiple Experimental Treatments.

The increase in the popularity of non-inferiority clinical trials represents the increasing need to search for substitutes for some reference (standard) treatments. A new treatment would be preferred to the standard treatment if the benefits of adopting it outweigh a possible clinically insignificant reduction in treatment efficacy (non-inferiority margin). Statistical procedures have recently been developed for treatment comparisons in non-inferiority clinical trials that have multiple experimental (new) treatments. An ethical concern for non-inferiority trials is that some patients undergo the less effective treatments; this problem is more serious when multiple experimental treatments are included in a balanced trial in which the sample sizes are the same for all experimental treatments. With the aim of giving fewer patients the inferior treatments, we propose a response-adaptive treatment allocation scheme that is based on the doubly adaptive biased coin design. The proposed adaptive design is also shown to be superior to the balanced design in terms of testing power.

Point success rate for patient therapeutic response prediction by continuous biomarker scores.

Various predictive diagnostic tests are highly demanded to guide optimal treatments for individual patients, as individual patients with the same disease such as cancer frequently exhibit dramatically different therapeutic responses to multiple available treatment options. A large number of clinical trials have thus been performed to test the predictive ability and utility of various therapeutic biomarker tests. However, in these trial designs the conventional optimization criteria such as positive predictive value or negative predictive value cannot reflect each patient's true chance of success associated with continuous predictive biomarker scores. We have developed a novel statistical concept, point success rate (PSR), to overcome deficiencies in these conventional methods for optimizing biomarker-based clinical trials. We demonstrate statistical superiority as well as clinical improvement by a PSR-based treatment selection both with simulated and breast cancer patient data.

A Unified Family of Covariate-Adjusted Response-Adaptive Designs Based on Efficiency and Ethics.

Response-adaptive designs have recently attracted more and more attention in the literature because of its advantages in efficiency and medical ethics. To develop personalized medicine, covariate information plays an important role in both design and analysis of clinical trials. A challenge is how to incorporate covariate information in response-adaptive designs while considering issues of both efficiency and medical ethics. To address this problem, we propose a new and unified family of covariate-adjusted response-adaptive (CARA) designs based on two general measurements of efficiency and ethics. Important properties (including asymptotic properties) of the proposed procedures are studied under categorical covariates. This new family of designs not only introduces new desirable CARA designs, but also unifies several important designs in the literature. We demonstrate the proposed procedures through examples, simulations, and a discussion of related earlier work.

Outcome-adaptive randomization for a delayed outcome with a short-term predictor: imputation-based designs.

Delay in the outcome variable is challenging for outcome-adaptive randomization, as it creates a lag between the number of subjects accrued and the information known at the time of the analysis. Motivated by a real-life pediatric ulcerative colitis trial, we consider a case where a short-term predictor is available for the delayed outcome. When a short-term predictor is not considered, studies have shown that the asymptotic properties of many outcome-adaptive randomization designs are little affected unless the lag is unreasonably large relative to the accrual process. These theoretical results assumed independent identical delays, however, whereas delays in the presence of a short-term predictor may only be conditionally homogeneous. We consider delayed outcomes as missing and propose mitigating the delay effect by imputing them. We apply this approach to the doubly adaptive biased coin design (DBCD) for motivating pediatric ulcerative colitis trial. We provide theoretical results that if the delays, although non-homogeneous, are reasonably short relative to the accrual process similarly as in the iid delay case, the lag is also asymptotically ignorable in the sense that a standard DBCD that utilizes only observed outcomes attains target allocation ratios in the limit. Empirical studies, however, indicate that imputation-based DBCDs performed more reliably in finite samples with smaller root mean square errors. The empirical studies assumed a common clinical setting where a delayed outcome is positively correlated with a short-term predictor similarly between treatment arm groups. We varied the strength of the correlation and considered fast and slow accrual settings.

Balancing continuous covariates based on Kernel densities.

The balance of important baseline covariates is essential for convincing treatment comparisons. Stratified permuted block design and minimization are the two most commonly used balancing strategies, both of which require the covariates to be discrete. Continuous covariates are typically discretized in order to be included in the randomization scheme. But breakdown of continuous covariates into subcategories often changes the nature of the covariates and makes distributional balance unattainable. In this article, we propose to balance continuous covariates based on Kernel density estimations, which keeps the continuity of the covariates. Simulation studies show that the proposed Kernel-Minimization can achieve distributional balance of both continuous and categorical covariates, while also keeping the group size well balanced. It is also shown that the Kernel-Minimization is less predictable than stratified permuted block design and minimization. Finally, we apply the proposed method to redesign the NINDS trial, which has been a source of controversy due to imbalance of continuous baseline covariates. Simulation shows that imbalances such as those observed in the NINDS trial can be generally avoided through the implementation of the new method.

Adaptive randomization for clinical trials.

In February 2010, the U.S. Food and Drug Administration (FDA, 2010 ) drafted guidance that discusses the statistical, clinical, and regulatory aspects of various adaptive designs for clinical trials. An important class of adaptive designs is adaptive randomization, which is considered very briefly in subsection VI.B of the guidance. The objective of this paper is to review several important new classes of adaptive randomization procedures and convey information on the recent developments in the literature on this topic. Much of this literature has been focused on the development of methodology to address past criticisms and concerns that have hindered the broader use of adaptive randomization. We conclude that adaptive randomization is a very broad area of experimental design that has important application in modern clinical trials.

Generalized multidimensional dynamic allocation method.

Dynamic allocation has received considerable attention since it was first proposed in the 1970s as an alternative means of allocating treatments in clinical trials which helps to secure the balance of prognostic factors across treatment groups. The purpose of this paper is to present a generalized multidimensional dynamic allocation method that simultaneously balances treatment assignments at three key levels: within the overall study, within each level of each prognostic factor, and within each stratum, that is, combination of levels of different factors Further it offers capabilities for unbalanced and adaptive designs for trials. The treatment balancing performance of the proposed method is investigated through simulations which compare multidimensional dynamic allocation with traditional stratified block randomization and the Pocock-Simon method. On the basis of these results, we conclude that this generalized multidimensional dynamic allocation method is an improvement over conventional dynamic allocation methods and is flexible enough to be applied for most trial settings including Phases I, II and III trials.