论文标题

结合目标试验和估算框架来定义因果估计:使用现实世界数据的应用程序将单臂试验置于上下文

Combining the target trial and estimand frameworks to define the causal estimand: an application using real-world data to contextualize a single-arm trial

论文作者

Hampson, Lisa V, Chu, Jufen, Zia, Aiesha, Zhang, Jie, Hsu, Wei-Chun, Parzynski, Craig, Hao, Yanni, Degtyarev, Evgeny

论文摘要

单臂试验(SAT)可用于支持在有很高未满足的医疗需求和高度有希望的早期疗效数据破坏随机分组所需的设置的情况下。在这种情况下,可以使用患者级的现实世界数据(RWD)来创建外部控制组(ECA),以将SAT结果与上下文化。但是,如果对(联合国)测量的预后因素不平衡,SAT与其ECA的天真比较将产生因果影响的偏差估计。有几种方法可以调整以进行测量的混杂,但是除非明确定义了感兴趣的因果问题,否则这种分析的解释是具有挑战性的,并且估计器与估算值保持一致。当ECA中的患者有资格在多个时间点上获得SAT时,就会出现其他并发症。在本文中,我们使用一种新型CAR-T治疗的关键SAT进行案例研究,以进行大量预处理的卵泡淋巴瘤患者,以说明如何使用目标试验和ICH E9(R1)估计框架的组合来定义与ECA和MACTISS SAT和MACTIS SATISONS相关的目标估计和避免与ECA的常见方法相关的常见方法。我们还提出了一种方法,以应对如何在几个时间点上符合SAT包含/排除标准的外部控件定义适当时间零的挑战。使用目标试验和估计框架有助于内部和外部利益相关者之间的讨论,以及对可用RWD充分性的早期评估。

Single-arm trials (SATs) may be used to support regulatory submissions in settings where there is a high unmet medical need and highly promising early efficacy data undermine the equipoise needed for randomization. In this context, patient-level real-world data (RWD) may be used to create an external control arm (ECA) to contextualize the SAT results. However, naive comparisons of the SAT with its ECA will yield biased estimates of causal effects if groups are imbalanced with regards to (un)measured prognostic factors. Several methods are available to adjust for measured confounding, but the interpretation of such analyses is challenging unless the causal question of interest is clearly defined, and the estimator is aligned with the estimand. Additional complications arise when patients in the ECA are eligible for the SAT at multiple timepoints. In this paper, we use a case-study of a pivotal SAT of a novel CAR-T therapy for heavily pre-treated patients with follicular lymphoma to illustrate how a combination of the target trial and the ICH E9(R1) estimand frameworks can be used to define the target estimand and avoid common methodological pitfalls related to the design of the ECA and comparisons with the SAT. We also propose an approach to address the challenge of how to define an appropriate time zero for external controls who meet the SAT inclusion/exclusion criteria at several timepoints. Use of the target trial and estimand frameworks facilitates discussions amongst internal and external stakeholders, as well as an early assessment of the adequacy of the available RWD.

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