# Likelihood Approaches for Trial Designs in Early Phase Oncology

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1 Likelihood Approaches for Trial Designs in Early Phase Oncology Clinical Trials Elizabeth Garrett-Mayer, PhD Cody Chiuzan, PhD Hollings Cancer Center Department of Public Health Sciences Medical University of South Carolina April 24, 2014

2 Practicalities of Early Phase Oncology Trials Small sample sizes Conservation of resources patients time funding Ethics early stopping protection of (sick) patients Recent Emphasis on Adaptive trial designs Bayesian? Controversies over priors CRM: Both Bayesian and Likelihood implementations

3 Common Problems with Oncology Clinical Trials 1 No early stopping for futility 2 No safety stopping rules in efficacy trials 3 Poor characterization of properties of phase I design

4 Today s Talk: Simple Likelihood Approaches for Addressing Common Problems The Likelihood Approach principles multiple looks The Sequential Probability Ratio Test (SPRT) Phase I Designs Phase II Designs

5 The Likelihood or Evidential Paradigm Based on the Law of Likelihood: If hypothesis A implies that the probability of observing some data X is P A (X), and hypothesis B implies that the probability is P B (X), then the observation X = x is evidence supporting A over B if P A (x) > P B (x), and the likelihood ratio, P A(x) P B (x), measures the strength of that evidence. (Hacking (1965); Royall (1997))

6 Likelihood Approach Determine what the data say about the parameter of interest Likelihood function: gives a picture of the data Likelihood interval(li): gives a range of reasonable values for the parameter of interest

7 Likelihood Ratios Take ratio of heights of L for different values of λ L(λ = 0.030) = 0.78; L(λ = 0.035) = 0.03 LR = = 26

8 Key difference in likelihood vs. frequentist paradigm Consideration of the alternative hypothesis Frequestist hypothesis testing H 0 : null hypothesis H 1 : alternative hypothesis Frequentist p-values: Calculated assuming null is true Ignores the alternative hypothesis Likelihood Ratio: Compares evidence for the two specified hypotheses Acceptance of rejection of null depends on the alternative

9 Example Assume H 0 : λ = 0.12 vs. H 1 : λ = 0.08 What if true λ = 0.10? Simulated data, N = 300 Frequentist: p = 0.01, reject the null Likelihood: LR = 1 4, weak evidence in favor of null

10 Example Why? P-value looks for evidence against the null LR compares evidence for both hypotheses When the truth is in the middle, which makes more sense?

11 Likelihood Inference Three possible results: Strong evidence for H 0, strong evidence for H 1, or weak evidence Weak evidence: at the end of the study, there is not sufficiently strong evidence in favor of either hypothesis This can be controlled by choosing a large enough sample size But, if neither hypothesis is correct, can end up with weak evidence even if N is seemingly large Strong evidence Correct evidence: strong evidence in favor of correct hypothesis Misleading evidence: strong evidence in favor of the incorrect hypothesis Analogous to type I and type II errors How can we control these?

12 Misleading Evidence in Universal bound: Under H 0, P ( ) L1 k 1 L 0 k (Birnbaum, 1962; Smith, 1953) In words, the probability that the likelihood ratio exceeds k in favor of wrong hypothesis can be no larger than 1 k In certain cases, an even lower bound applies Royall, 2000 Difference in normal means Large sample size Common choices for k are 8 (strong), 10, 32 (very strong).

13 Implications Important result: For a sequence of independent observations, the universal bound still holds (Robbins, 1970) Implication: We can look at the data as often as desired and our probability of misleading evidence is bounded That is, if k = 10, the probability of misleading strong evidence is 10% k = 10 seems reasonable considering β = 10 20% and α = 5 10% in most studies

14 Sequential Probability Ratio Test This is not a new idea Abraham Wald (1945) published Sequential Tests of Statistical Hypotheses in the Annals of Mathematical Statistics (it s 70 pages long) Commonly seen in DSMB plans SPRT used to monitor secondary safety outcomes Classical SPRT assumes two boundaries: Stop if there is strong evidence for H 0 Stop if there is strong evidence for H 1 Generally setup based on A and B which are based on selected α and β levels

15 Wald s Figure 2 The context was not clinical trials The initial result was useful for the war effort in 1943 and essentially classified until 1945 Popular in manufacturing, item response theory, etc. Max SPRT (Kulldorf et al., 2011) with applications to medical research, specifically rare adverse events

16 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Most immunotherapy trials in cancer use a two-step approach to dose finding 1 Perform an algorithmic design to identify safe doses 2 Collect immunologic data and explore it to see if there appears to be an optimal dose Optimal dose? we imagine there will be a clear plateau in the association between dose and immunoresponse unrealistic and simplistic due to small sample sizes at each dose unrealistic and simplistic due to heterogeneity across patients

17 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Goal: Develop an adaptive early phase design for assessing toxicity and efficacy outcomes in cancer immunotherapy trials. Identify the optimal dose to maximize efficacy while maintaining safety. Two-stage design: Stage 1: Explore doses for safety and obtain information on immunotherapy outcomes Stage 2: Allocate patients to allowable doses with emphasis towards doses with higher efficacy Uses both: continuous (immunologic) outcomes binary toxicity information Optimize efficacy while setting a threshold on acceptable toxicity

18 Stage 1: Confirm Safety Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Define p 1 and p 2 as unacceptable and acceptable DLT rates Use cohorts of size m to explore selected dose levels Likelihood inference used to declare dose levels allowable based on p 1 and p 2 and observed data. Define k as the threshold of evidence required for declaring a dose to be toxic At end of Stage 1, there will be a set of doses for Stage 2. Continue to Stage 2 if two or more allowable doses. Details in Chiuzan et al. 2014

19 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Likelihood method with cohorts of size 3 Example: p 1 = 0.40; p 2 = 0.15; m = 3 Require likelihood ratio 2 (in favor of p 1 ) to declare toxic. 0 or 1 DLT in 3 pts: allowable dose 2 or 3 DLTs in 3 pts: unacceptable dose (and all higher doses unacceptable) DLT 3+3 rule L(p 1 )/L(p 2 ) k = 1 k = 2 k = 8 0 acceptable LR = 0.35 acceptable acceptable weak 1 expand to 6 LR = 1.33 toxic weak weak 2 toxic LR = 5.0 toxic toxic weak 3 toxic LR = 19.0 toxic toxic toxic toxic: LR k; acceptable: LR 1 k ; weak: 1 k < LR < k

20 Stage 2: Adaptive randomization Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Using data from Stage 1, estimate immunologic parameter estimate at each of J allowable doses. Example: T cell persistence at 14 days. y i = % CD3 cells of patient i at 14 days compared to baseline d i = dose level for patient i Estimation is based on a standard linear regression model using a log transformation of y i : log(y i ) = β 0 + J j=1 β ji(d i = j) + e i e i N(0, σ 2 ); j β j = 0

21 Stage 2: Adaptive randomization Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Define p j as the estimated persistence (%) at dose j: ˆp j = e ˆβ 0 + ˆβ j Calculate the randomization probabilities π j for doses j = 1,.., J: π j = or π j = ˆp j r ˆpr ˆpj r ˆpr

22 Example 1: shallow slope Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Tcell persistence (% of baseline) Dose Level

23 Example 1: shallow slope Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Tcell persistence (% of baseline) Dose Level

24 Example 1: shallow slope Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Tcell persistence (% of baseline) π 1= 0.14 π 2 = 0.2 π 3= 0.33 π 4= Dose Level

25 Example 2: steep slope Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Tcell persistence (% of baseline) Dose Level

26 Example 2: steep slope Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Tcell persistence (% of baseline) Dose Level

27 Example 2: steep slope Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Tcell persistence (% of baseline) π 1= 0.05 π 2= 0.13 π 3= 0.33 π 4= Dose Level

28 Stage 2 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy For the first patient in Stage 2, randomize to allowable doses j = 1,.., J based on π j. As data becomes available, update randomization probabilities for accruing patients. Repeat until total sample size is achieved, or some other stopping criteria is met. When DLTs are observed, utilize likelihood inference to determine if dose is toxic.

29 Example: cohort of size 5 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Example: p 1 = 0.40; p 2 = 0.15 Require likelihood ratio 2 (in favor of p 1 ) to declare toxic. 0 or 1 DLT in 5 pts: allowable dose 2 DLTs in 5 pts: unacceptable dose (and all higher doses unacceptable) DLT L(p 1 )/L(p 2 ) k = 1 k = 2 k = 8 0 LR = 0.18 acceptable acceptable weak 1 LR = 0.66 acceptable weak weak 2 LR = 5.0 toxic toxic weak 3 LR = 19.0 toxic toxic toxic toxic: LR k; acceptable: LR 1 k ; weak: 1 k < LR < k

30 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Aside: The 3+3 provides weak evidence for DLT rate H 0 : p 0 = 0.40 H 1 : p 1 = 0.15 DLT (n) 3+3 rule L(p 1 )/L(p 0 ) k = 1 k = 2 k = 8 0(3) acceptable LR = 2.84 acceptable acceptable weak 1(3) + 0(3) acceptable LR = 2.14 acceptable acceptable weak 2(3) toxic LR = 0.20 toxic toxic weak 3(3) toxic LR = 0.05 toxic toxic toxic 1(3) + 1(3) toxic LR = 0.57 toxic weak weak 1(3) + 2(3) toxic LR = 0.15 toxic toxic weak 1(3) + 3(3) toxic LR = 0.04 toxic toxic toxic Dose limiting toxicities (cohort size) Acceptable: LR k; toxic: LR 1/k; weak: 1/k < LR < k

31 Constrained Adaptive Randomization Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy Simulations: Six toxicity and five efficacy models; two variance structures; two sample sizes Safety constraints implemented using H 1 : p 1 = 0.40; H 2 : p 2 = 0.15; k = 2 Subset presented: six toxicity scenarios Plateau efficacy model Large variance across patients Smaller sample size (N = 25)

32 Results: Stage 1 & 2 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy DLT rates: 0.05, 0.07, 0.10, 0.12, 0.15

33 Results: Stage 1 & 2 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy DLT rates: 0.25, 0.25, 0.25, 0.25, 0.25

34 Results: Stage 1 & 2 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy DLT rates: 0.05, 0.18, 0.29, 0.40, 0.51

35 Results: Stage 1 & 2 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy DLT rates: 0.05, 0.42, 0.48, 0.50, 0.52

36 Results: Stage 1 & 2 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy DLT rates: 0.02, 0.02, 0.02, 0.02, 0.02

37 Results: Stage 1 & 2 Stage 1 Stage 2 Stages 1 & 2: Toxicity and Efficacy DLT rates: 0.02, 0.05, 0.28, 0.40, 0.50

38 Phase II: Sequential Trial Design Motivating Example Single arm cancer clinical trial Outcome = clinical response Early stopping for futility Standard frequentist approach Simon two-stage design Only one look at the data Determine optimality criterion minimax minimum E(N) under H0 (Simon s optimal) Likelihood approach Use binomial likelihood Can look at the data after each observation

39 Phase II: Sequential Trial Design Motivating Example New cancer treatment agent Anticipated response rate is 40% (p 2 = 0.40) Null response rate is 20% (p 1 = 0.20) the standard of care yields 20% not worth pursuing new treatment with same response rate as current treatment Using frequentist approach: Simon two-stage with α = β = 0.10 Optimum criterion: smallest E(N) First stage: enroll 17. If 4 or more respond, continue Second stage: enroll 20. If 11 or more respond, conclude success. Maximum sample size = 37

40 Implementation Look at the data after each patient Estimate the difference in log(l 1 ) and log(l 2 ) Rules: If log(l 1 ) log(l 2 ) log(k): stop for futility If log(l 1 ) log(l 2 ) < log(k): continue enrolling patients

41 Stopping Rules Given discrete nature, only certain looks provide an opportunity to stop Current example: stop the study if 0 responses in 9 patients 1 response in 12 patients 2 responses in 15 patients 3 responses in 19 patients 4 responses in 22 patients 5 responses in 26 patients 6 responses in 29 patients 7 responses in 32 patients Number of Responses Continue Study Stop Study for Futility Although total N can be as large as 37, there are only 8 thresholds for futility early stopping assessment Sample size

42 Design Performance Characteristics How does the proposed approach compare to the optimal Simon two-stage design? What are performance characteristics we would be interested in? small E(N) under the null hypothesis frequent stopping under null infrequent stopping under alternative acceptance of H 1 under H 1 acceptance of H 2 under H 2

43 Simon Optimal vs. Likelihood Probability Accept HA, Lik Accept H0, Lik Weak Evidence Accept HA, Simon Accept H0, Simon True p

44 Probability of Early Stopping Probability of Stopping Early Likelihood (optimal N) Likelihood (minmax N) Simon Optimal Simon MinMax True p

45 Expected Sample Size Expected Sample Size Likelihood (optimal N) Likelihood (minmax N) Simon Optimal Simon MinMax True p

46 Bayesian Competitor: Predictive Probability Lee and Liu, Clinical Trials, Bayesian but without loss function (no Bayes risk) Searches for design parameters to ensure size and power Prior is chosen so that mean of prior is the null hypothesis, but it s a weak prior. Predictive probability (P P ) = probability that the end result of the trial is positive given current data and data to be observed Based on the probability that the true response rate is greater than the null response rate. Ignores the alternative

47 Bayesian Competitor Predictive Probability Stopping: Based on pre-defined thresholds, θ L and θ U If P P < θ L : stop the trial and reject alternative If P P > θ U : stop the trial and reject the null (but often θ U = 1) At pre-specified times, the predictive probability is calculated Lee and Liu explore difference frequency of looks Comparisons here are for looking at every patient θ T is defined as the threshold for determining efficacy at the trial s end θ T and θ U do not have the same stringency

48 Comparison of Designs P ET 1 E(N 1 ) Simon Two-Stage Predictive Probability Likelihood

49 Monitoring Safety Can be used to monitor safety, e.g. transplant-related mortality It is set-up so that too many events trigger stopping (instead of too few) More appropriate than: Repeated confidence intervals repeated p-values (controlling alpha?) Like a one-sided SP RT

50 Evidential methods have been around a long time They allow us to: Simply quantify evidence for competing hypotheses Evaluate the data frequently with bounded probability of misleading evidence Likelihood methods are simple to implement and require no prior Sufficient work has been done to justify K thresholds for Phase III trials More work should be done to provide reasonable guidance on appropriate K in early phase trials

51 Thank you! Work supported by the NIH grant, P01 CA and by the Biostatistics Shared Resource, Hollings Cancer Center, MUSC (P30 CA138313)

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