Using short-term endpoints to improve interim decision making and trial duration in two-stage phase II trials with nested binary endpoints

In oncology, phase II clinical trials are often planned as single-arm two-stage designs with a binary endpoint, for example, progression-free survival after 12 months, and the option to stop for futility after the first stage. Simon's two-stage design is a very popular approach but depending on the follow-up time required to measure the patients' outcomes the trial may have to be paused undesirably long. To shorten this forced interruption, it was proposed to use a short-term endpoint for the interim decision, such as progression-free survival after 3 months. We show that if the assumptions for the short-term endpoint are misspecified, the decision-making in the interim can be misleading, resulting in a great loss of statistical power. For the setting of a binary endpoint with nested measurements, such as progression-free survival, we propose two approaches that utilize all available short-term and long-term assessments of the endpoint to guide the interim decision. One approach is based on conditional power and the other is based on Bayesian posterior predictive probability of success. In extensive simulations, we show that both methods perform similarly, when appropriately calibrated, and can greatly improve power compared to the existing approach in settings with slow patient recruitment. Software code to implement the methods is made publicly available.