Thanks to Martin Bland, Rebecca Walwyn, Graham Wetherill, and John Hughes for their thoughtfulness and helpful input. My supervisor's question concerned underpowered phase II studies (question immediately below). I received reference recommendations through other channels. I would like to share these at the very bottom. Brett P.S. Additional thought or references would be very welcome. * * * Brett Larive [log in to unmask] Dept of Biostatistics/Wb4 phone: 216-444-9925 Cleveland Clinic Foundation fax: 216-445-2781 9500 Euclid Avenue Cleveland, OH 44195 QUESTION: 1. Frequently we confront clinical investigators who wish to perform randomized clinical trials using a clinical endpoint as the primary outcome, but due to funding or logistical constraints can employ limited sample sizes which are sufficient to detect only very large effects. The detectable effect size is typically regarded as not totally outside the realm of possibility, but larger than is expected and much larger than the minimum clinically imortant effect. In an attempt to lend respectability to the trial the investigators tend to use the term "Pilot Study" to refer to it, as a way of acknowleging the limited power. However, from our statistical persecptive such studies are not true pilot studies because there are no concrete plans to follow them with definative Phase 3 trials with adequate power. The clinical investigators' logic typically is that if their study shows "interesting trends", then there may be a reasonable chance of convincing funding agencies to support a definitive trial in the future. There is an extensive statistical literature on Phase II clincial trials conducted for the explicit purpose of screening interventions to determine which interventions should be evaluated in Phase III trials. There is also a literature dealing with preliminary trials for screening interventions based on surrogate endpoints, with the idea that interventions shown to effect the surrogate endpoints would then be investigated in full scale trials. There is also a literature on the conduct of true pilot studies, defined as preliminary trials to evaluate logistical issues regarding the conduct of a planned full-scale phase III trial. But the scenario we are concerned with does not appear to fall into any of these 3 categories because there is no clear linkage between the conduct of the proposed trial with a future adquately powered phase 3 trial. To our knowlege, the statistical literature refers to such trials as underpowered Phase 3 studies and strongly discourages their conduct. But given the high frequency of such "low-powered" Phase 3 trials in spite of the best efforts of statisticians, we would like to investigate what statistical approaches may have been developed that may be appropriate to guide their design and analysis. Clearly, bayesian approaches might be considered. We would be interested in the perspective of others regarding this issue. To: Brett Larive <[log in to unmask]> Subject: Re: QUERY: alternatives to underpowered Phase 3 studies From: [log in to unmask] Date: Fri, 20 Feb 2004 15:50:47 +0000 Dear Brett, I would be very interested in any responses you receive as it is a topic that ties in very closely with my own work. I have not been working in this area long but my current impression is that psychiatry, or mental health more generally, is one of the hot spots for underpowered phase 3 trials. A few discussions have led me to wonder whether part of the reason for this is the lack of a well accepted route to conducting definitive randomised trials in this area. Many of the interventions are complex and I am beginning to become aware of the literature there. Some of this is starting to impose a structure on this aspect of the problem but I am not sure that opinion has progressed as far as it needs to to influence how these trials are funded. In a large proportion of the trials I come across the interventions are not drug treatments or they involve a combination of drug and non-drug treatments. It seems to me that investigators are trying to attach terminology found elsewhere to describe where they think they are on route to a definitive trial. This seems to have led to different usages of terminology and some confusion (on my part at least!). My feeling is that there is a more accepted route to funding a phase III trial for a drug intervention and that this includes funding for phase I and phase II trials. In contrast the route to funding a phase III trial of non-drug interventions seems to be more fuzzy and the Medical Research Council, UK has recently conducted a review ('Clinical Trials for Tomorrow') which has highlighted this. I am hoping that when this is resolved the definitive trials in this area will be a more distinct category and will be appropriately powered for the purpose. In the meantime I think investigators see possibilities for funding non-definitive trials by dressing them up as if they were definitive. Best wishes Rebecca Rebecca Walwyn Statistician Clinical Trials Unit Institute of Psychiatry 103 Denmark Hill London SE5 8AZ England From: "Graham Wetherill" <[log in to unmask]> To: "Brett Larive" <[log in to unmask]> Subject: RE: QUERY: alternatives to underpowered Phase 3 studies Date: Fri, 20 Feb 2004 17:38:23 -0000 Brett, I have no magic solutions. I do not know if sequential trials could solve your problem - perhaps only if the treatment time is short (i.e. results are known very quickly after recruitment. Potentially, a 2-stage design could limit expenditure if there were no hint of interesting results. - This might require a change in attitude from funding authorities. Sometimes trials are designed with the "gold standard" as primary, with less chance of success, where a good primary stands a much better chance of success. It would be interesting to calculate the power, average sample size, etc from the scenario described below (i.e. average total sample size and average total cost from pilot plus main) - it would require some assumptions about what would be "interesting trends". Graham Date: Sun, 22 Feb 2004 16:11:25 +0000 From: jmhughes <[log in to unmask]> To: Brett Larive <[log in to unmask]> Subject: QUERY: alternatives to underpowered Phase 3 studies Dear Brett, I must declare an interest. I am a member of an ethical committee but the views expressed are entirely my own. It seems to me that the prosposed study is unethical because the detectable effect is "much larger than the minimum clinically important effect". Consequently patients are put at risk apparently only for the purpose of raising "a reasonable chance of convincing funding agencies" for support. This is not an ethical aim of a clinical trial. Furthermore if the trial is so low powered any significant difference found would presumably have arisen by chance. If there is any value in the proposed treatment its clinical benefit should be assessed by an adequately powered clinical trial. John Hughes Date: Thu, 26 Feb 2004 11:17:41 +0000 From: "Bland, M." <[log in to unmask]> To: Brett Larive <[log in to unmask]> Subject: Re: QUERY: alternatives to underpowered Phase 3 studies I do not think that Bayesian methods will really help. If the study is not big enough, it is not big enough however you analyse it. I think that such studies are best termed "exploratory". The aim is not to produce a definitive answer to a question, but to explore whether answering the question would be worthwhile. Conventional sample size calculations are therefore irrelevant. They are designed for the definitive study. I agree entirely that "pilot" is the wrong word. Pilot studies are small studies to test data collection etc., not to produce findings of interest in their own right. Martin REFERENCES RECOMMENDED FROM OTHER SOURCES: Estey, Thall et al. Blood, 99:4343-4349, 2002 Inoue, Thall and Berry, Biometrics 58:823-831, 2002 Thall et al. Biometrika 75:303-310, 1988 Schaid et al. Biometrika 77:5057-513, 1990 Thall, Cook. "Dose-Finding Based on Efficacy-Toxicity Trade-Offs" Biometrics (to appear) Martin Posch, Peter Bauer, Werner Brannath (2003), Issues in designing flexible trials. Statistics in Medicine, Volume 22, Issue 6, Date: 30 March 2003, Pages: 953-969 P.Y. Liu. "Phase II Selection Designs" from Handbook of Statistics in Clinical Oncology, John Crowley editor, Marcel Dekker 2001, 082479025 P.Y. Liu, M LeBlanc, M Desai. "Fals positive rates of randomized phase II designs." Controlled Clinical Trials 1999; 20:343-352 Berry DA (2003). Statistical Innovations in Cancer Research. In Cancer Medicine e.6. Ch 33, pp 465-478. London: BC Decker. (Ed: Holland J, Frei T et al.) Berry DA (2004). Bayesian statistics and the efficiency and ethics of clinical trials. Statistical Science 18. (To appear.) Coffey CS and Muller KE. (2003) Properties of Internal Pilots with the Univariate Approach to Repeated Measures, Statistics in Medicine, 22: 2469-2485.