The Use of Net Benefit in Modeling Non-Proportional Hazards

Abstract

Background: The hazard ratio (HR), representing the quantified estimate of treatment effect in survival analysis, measures the instantaneous relative difference of failure risk between two groups. The HR is typically assumed to be independent of time; however, this assumption is usually violated in practice. If the proportionality assumption holds, HR can be validly with the popular Cox proportional hazards model. When not proportional, the Wilcoxon-Gehan has been proposed to test the hypothesis of no difference. These have been recently generalized to evaluate differences in survival time for more than zero survival differences (the “net survival benefit”). Method: In this thesis, an attempt is made to illustrate the properties of generalized Wilcoxon Gehan tests as proposed by Buyse (2009). We use the concept of net survival benefit to re-analyze the trial by the Gastrointestinal Tumor Study Group (1982) by comparing chemotherapy versus combined chemotherapy and radiation in the treatment of locally unresectable gastric cancer. Survival times in days, for the 45 patients were recorded in each treatment arm. In that trial, a delayed treatment effect was observed, thus the HR is non-proportional. To provide a flexible assessment of the treatment effect, the net survival benefit was computed using datasets simulated under typical scenarios of proportional hazards, such as delayed treatment effect. Results: The generalized Wilcoxon statistic U, favored not adding radiation to chemotherapy, but only for survival up to 12 months. At Δ=0, U (0) = 491. In the simulated data sets, the confidence interval under the null hypothesis U (0) is (-152, 388). The test statistic 491 is outside this interval indicating radiation treatment might be beneficial. At U(12) = 219, it is inside the confidence interval of no treatment effect (-154,268) indicating the benefit of Chemo only is gone after 12 months. Conclusions: The net survival benefit measured via Buyse’s generalized Wilcoxon statistic is a measure of treatment effect that is meaningful whether or not hazards are proportional. The associated statistical test is more powerful than the standard log-rank test when a delayed treatment effect is anticipated.