Comparing the Survival of Two Groups with an Intermediate Clinical Event

Abstract

Consider a subject entered on a clinicaltrial in which the major endpoint is a time metric such as deathor time to reach a well defined event. During the observationalperiod the subject may experience an intermediate clinical event.The intermediate clinical event may induce a change in the survivaldistribution. We consider models for the one and two sample problem.The model for the one sample problem enables one to test if theoccurrence of the intermediate event changed the survival distribution.This models provides a way of carrying out non-randomized clinicaltrial to determine if a therapy has benefit. The two sample problemconsiders testing if the probability distributions, with andwithout an intermediate event, are the same. Statistical testsare derived using a semi-Markov or a time dependent mixture model.Simulation studies are carried out to compare these new procedureswith the log rank, stratified log rank and landmark tests. Thenew tests appear to have uniformly greater power than these competitortests. The methods are applied to a randomized clinical trialcarried out by the Aids Clinical Trial Group (ACTG) which comparedlow versus high doses of zidovudine (AZT).