Personalized medicine, a paradigm of medicine tailored to a patient's characteristics, is an increasingly attractive field in health care. An important goal of personalized medicine is to identify a ...subgroup of patients, based on baseline covariates, that benefits more from the targeted treatment than other comparative treatments. Most of the current subgroup identification methods only focus on obtaining a subgroup with an enhanced treatment effect without paying attention to subgroup size. Yet, a clinically meaningful subgroup learning approach should identify the maximum number of patients who can benefit from the better treatment. In this article, we present an optimal subgroup selection rule (SSR) that maximizes the number of selected patients, and in the meantime, achieves the pre‐specified clinically meaningful mean outcome, such as the average treatment effect. We derive two equivalent theoretical forms of the optimal SSR based on the contrast function that describes the treatment‐covariates interaction in the outcome. We further propose a constrained policy tree search algorithm (CAPITAL) to find the optimal SSR within the interpretable decision tree class. The proposed method is flexible to handle multiple constraints that penalize the inclusion of patients with negative treatment effects, and to address time to event data using the restricted mean survival time as the clinically interesting mean outcome. Extensive simulations, comparison studies, and real data applications are conducted to demonstrate the validity and utility of our method.
Rifampin has acute inhibitory and chronic inductive effects that can cause complex drug–drug interactions. Rifampin inhibits transporters including organic‐anion‐transporting polypeptide (OATP)1B and ...P‐glycoprotein (P‐gp), and induces enzymes and transporters including cytochrome P450 3A, UDP‐glucuronosyltransferase (UGT)1A, and P‐gp. This study aimed to separate inhibitory and inductive effects of rifampin on letermovir disposition and elimination (indicated for cytomegalovirus prophylaxis in hematopoietic stem cell transplant recipients). Letermovir is a substrate of UGT1A1/3, P‐gp, and OATP1B, with its clearance primarily mediated by OATP1B. Letermovir (single‐dose) administered with rifampin (single‐dose) resulted in increased letermovir exposure through transporter inhibition. Chronic coadministration with rifampin (inhibition plus potential OATP1B induction) resulted in modestly decreased letermovir exposure vs. letermovir alone. Letermovir administered 24 hours after the last rifampin dose (potential OATP1B induction) resulted in markedly decreased letermovir exposure. These data suggest rifampin may induce transporters that clear letermovir; the modestly reduced letermovir exposure with chronic rifampin coadministration likely reflects the net effect of inhibition and induction. OATP1B endogenous biomarkers coproporphyrin (CP) I and glycochenodeoxycholic acid‐sulfate (GCDCA‐S) were also analyzed; their exposures increased after single‐dose rifampin plus letermovir, consistent with OATP1B inhibition and prior reports of inhibition by rifampin alone. CP I and GCDCA‐S exposures were substantially reduced with letermovir administered 24 hours after the last dose of rifampin vs. letermovir plus chronic rifampin coadministration. This study suggests that OATP1B induction may contribute to reduced letermovir exposure after chronic rifampin administration, although given the complexity of letermovir disposition alternative mechanisms are not fully excluded.
Randomized clinical trials are often designed to assess whether a test treatment prolongs survival relative to a control treatment. Increased patient heterogeneity, while desirable for ...generalizability of results, can weaken the ability of common statistical approaches to detect treatment differences, potentially hampering the regulatory approval of safe and efficacious therapies. A novel solution to this problem is proposed. A list of baseline covariates that have the potential to be prognostic for survival under either treatment is pre‐specified in the analysis plan. At the analysis stage, using all observed survival times but blinded to patient‐level treatment assignment, “noise” covariates are removed with elastic net Cox regression. The shortened covariate list is used by a conditional inference tree algorithm to segment the heterogeneous trial population into subpopulations of prognostically homogeneous patients (risk strata). After patient‐level treatment unblinding, a treatment comparison is done within each formed risk stratum and stratum‐level results are combined for overall statistical inference. The impressive power‐boosting performance of our proposed 5‐step stratified testing and amalgamation routine (5‐STAR), relative to that of the logrank test and other common approaches that do not leverage inherently structured patient heterogeneity, is illustrated using a hypothetical and two real datasets along with simulation results. Furthermore, the importance of reporting stratum‐level comparative treatment effects (time ratios from accelerated failure time model fits in conjunction with model averaging and, as needed, hazard ratios from Cox proportional hazard model fits) is highlighted as a potential enabler of personalized medicine. An R package is available at
https://github.com/rmarceauwest/fiveSTAR.
Rare variants are of increasing interest to genetic association studies because of their etiological contributions to human complex diseases. Due to the rarity of the mutant events, rare variants are ...routinely analyzed on an aggregate level. While aggregation analyses improve the detection of global-level signal, they are not able to pinpoint causal variants within a variant set. To perform inference on a localized level, additional information, e.g., biological annotation, is often needed to boost the information content of a rare variant. Following the observation that important variants are likely to cluster together on functional domains, we propose a protein structure guided local test (POINT) to provide variant-specific association information using structure-guided aggregation of signal. Constructed under a kernel machine framework, POINT performs local association testing by borrowing information from neighboring variants in the 3-dimensional protein space in a data-adaptive fashion. Besides merely providing a list of promising variants, POINT assigns each variant a p-value to permit variant ranking and prioritization. We assess the selection performance of POINT using simulations and illustrate how it can be used to prioritize individual rare variants in PCSK9, ANGPTL4 and CETP in the Action to Control Cardiovascular Risk in Diabetes (ACCORD) clinical trial data.
Copy number variants (CNVs) are the gain or loss of DNA segments in the genome that can vary in dosage and length. CNVs comprise a large proportion of variation in human genomes and impact health ...conditions. To detect rare CNV associations, kernel-based methods have been shown to be a powerful tool due to their flexibility in modeling the aggregate CNV effects, their ability to capture effects from different CNV features, and their accommodation of effect heterogeneity. To perform a kernel association test, a CNV locus needs to be defined so that locus-specific effects can be retained during aggregation. However, CNV loci are arbitrarily defined and different locus definitions can lead to different performance depending on the underlying effect patterns. In this work, we develop a new kernel-based test called CONCUR (i.e., copy number profile curve-based association test) that is free from a definition of locus and evaluates CNV-phenotype associations by comparing individuals' copy number profiles across the genomic regions. CONCUR is built on the proposed concepts of "copy number profile curves" to describe the CNV profile of an individual, and the "common area under the curve (cAUC) kernel" to model the multi-feature CNV effects. The proposed method captures the effects of CNV dosage and length, accounts for the numerical nature of copy numbers, and accommodates between- and within-locus etiological heterogeneity without the need to define artificial CNV loci as required in current kernel methods. In a variety of simulation settings, CONCUR shows comparable or improved power over existing approaches. Real data analyses suggest that CONCUR is well powered to detect CNV effects in the Swedish Schizophrenia Study and the Taiwan Biobank.
For survival analysis applications we propose a novel procedure for identifying subgroups with large treatment effects, with focus on subgroups where treatment is potentially detrimental. The ...approach, termed forest search, is relatively simple and flexible. All‐possible subgroups are screened and selected based on hazard ratio thresholds indicative of harm with assessment according to the standard Cox model. By reversing the role of treatment one can seek to identify substantial benefit. We apply a splitting consistency criteria to identify a subgroup considered “maximally consistent with harm.” The type‐1 error and power for subgroup identification can be quickly approximated by numerical integration. To aid inference we describe a bootstrap bias‐corrected Cox model estimator with variance estimated by a Jacknife approximation. We provide a detailed evaluation of operating characteristics in simulations and compare to virtual twins and generalized random forests where we find the proposal to have favorable performance. In particular, in our simulation setting, we find the proposed approach favorably controls the type‐1 error for falsely identifying heterogeneity with higher power and classification accuracy for substantial heterogeneous effects. Two real data applications are provided for publicly available datasets from a clinical trial in oncology, and HIV.
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