A Comparison of Estimand and Estimation Strategies for Clinical Trials in Early Parkinson's Disease

Parkinson's disease (PD) is a chronic, degenerative neurological disorder. PD cannot be prevented, slowed or cured as of today but highly effective symptomatic treatments are available. We consider relevant estimands and treatment effect estimators for randomized trials of a novel treatment which aims to slow down disease progression versus placebo in early, untreated PD. A commonly used endpoint in PD trials is the MDS-Unified Parkinson's Disease Rating Scale (MDS-UPDRS), which is longitudinally assessed at scheduled visits. The most important intercurrent events (ICEs) which affect the interpretation of the MDS-UPDRS are study treatment discontinuations and initiations of symptomatic treatment. Different estimand strategies are discussed and hypothetical or treatment policy strategies, respectively, for different types of ICEs seem most appropriate in this context. Several estimators based on multiple imputation which target these estimands are proposed and compared in terms of bias, mean-squared error, and power in a simulation study. The investigated estimators include methods based on a missing-at-random (MAR) assumption, with and without the inclusion of time-varying ICE-indicators, as well as reference-based imputation methods. Simulation parameters are motivated by data analyses of a cohort study from the Parkinson's Progression Markers Initiative (PPMI).