Evaluating causal effects on time-to-event outcomes in an RCT in Oncology with treatment discontinuation

In clinical trials, patients may discontinue treatments prematurely, breaking the initial randomization and, thus, challenging inference. Stakeholders in drug development are generally interested in going beyond the Intention-To-Treat (ITT) analysis, which provides valid causal estimates of the effect of treatment assignment but does not inform on the effect of the actual treatment receipt. Our study is motivated by an RCT in oncology, where patients assigned the investigational treatment may discontinue it due to adverse events. We propose adopting a principal stratum strategy and decomposing the overall ITT effect into principal causal effects for groups of patients defined by their potential discontinuation behavior. We first show how to implement a principal stratum strategy to assess causal effects on a survival outcome in the presence of continuous time treatment discontinuation, its advantages, and the conclusions one can draw. Our strategy deals with the time-to-event intermediate variable that may not be defined for patients who would not discontinue; moreover, discontinuation time and the primary endpoint are subject to censoring. We employ a flexible model-based Bayesian approach to tackle these complexities, providing easily interpretable results. We apply this Bayesian principal stratification framework to analyze synthetic data of the motivating oncology trial. We simulate data under different assumptions that reflect real scenarios where patients' behavior depends on critical baseline covariates. Supported by a simulation study, we shed light on the role of covariates in this framework: beyond making structural and parametric assumptions more credible, they lead to more precise inference and can be used to characterize patients' discontinuation behavior, which could help inform clinical practice and future protocols.