# Sample Size Calculation for Clinical Trials with Multiple Primary Endpoints

## 1. Introduction

The calculation of sample size or power is a difficult task when multiple primary endpoints (MPE) are considered, which means when there is more than one primary endpoint. In general, these MPE are categorized into multiple co-primary and multiple primary endpoints. A trial with multiple co-primary endpoints is successful if there is a significant improvement for ALL THE ENDPOINTS whereas in case of multiple primary endpoints a success in AT LEAST ONE ENDPOINT is sufficient. The package mpe can be used to calculate sample size and power for MPE.

First, we give some details about the methods and formulas. Next, we illustrate how to apply our functions in simple examples. Finally, we consider Alzheimer’s Disease (AD) as an application.

## 2. Multiple Co-primary Endpoints

In case of co-primary endpoints, the trial is designed to evaluate ALL THE ENDPOINTS. For example, in a clinical trial evaluating some treatments in patients affected by irritable bowel syndrome (IBS) the FDA recommends to evaluate ALL endpoints for assessing the IBS signs and symptoms. The co-primary endpoints are:

1. pain intensity and stool frequency of IBS with constipation
2. pain intensity and stool consistency of IBS with diarrhea (FDA 2012).

### 2.1. Known Covariance

In this section, we briefly state the relevant formulas from Chapter 2 of the book by Sozu et al. [12], where we assume the covariance as known. Let $$K$$ be the number of co-primary endpoints and $$Y_{C_k}$$ and $$Y_{T_k}$$ ($$k=1,\ldots,K$$) be the results for the control (C) and test (T) group in a randomized superiority clinical trial. $$Y_C=(Y_{C_1},\ldots,Y_{C_K})$$ and $$Y_T=(Y_{C_1},\ldots,Y_{C_K})$$ are assumed to follow a $$K$$-variate normal distribution with mean vector $$µ_C = (µ_{C_1},\ldots, µ_{C_K})$$ and $$µ_T = (µ_{T_1},\ldots,µ_{T_K})$$ and (known!) covariance matrix $$∑$$; i.e., $$Y_C \sim N_k(µ_C,∑)$$ and $$Y_T\sim N_k(µ_T,∑)$$.

where

$\mathbf{\Sigma} = \left[\begin{array} {ccc} \sigma_1^2 & ... & {\rho^1_K}{\sigma_1}{\sigma_K}\\ \vdots & \vdots & \vdots \\ {\rho^1_K}{\sigma_1}{\sigma_K}& ... & \sigma_K^2 \end{array}\right]$

As we are considering a superiority trial, the superiority of the test intervention over control in terms of all the $$K$$ primary endpoints is given if and only if $$µ_{T_k} - µ_{C_k} > 0$$ for all $$k = 1,2.....K$$. In statistical testing, the null hypothesis $$H_O$$ is rejected if and only if all of the null hypotheses associated with each of the $$K$$ primary endpoints are rejected at a significance level of $$\alpha$$. The rejection region is an intersection of the involved $$K$$ co-primary endpoints and the statistical test used for the analysis is called intersection-union test [2]. That is, we consider the following hypotheses

$$H_0 : µ_{T_k} - µ_{C_k} <= 0$$, for at least one $$k$$,

$$H_1 : µ_{T_k} - µ_{C_k} > 0$$, for all $$k$$.

As we are assuming the covariance to be known, the hypotheses can be tested using a multivariate (intersection-union) z-test implemented in function mpe.z.test. The test statistic reads

$Z_k = \frac{\sqrt{n}({\overline{Y_{T_k}} -\overline{Y_{C_k}}})}{\sqrt{2}\sigma_k}, \quad k = 1,2,\ldots, K$

where $$n$$ is the sample size per group (i.e., we assume a balanced design), and $$\overline{Y_{T_k}}$$ and $$\overline{Y_{C_k}}$$ are the respective sample means.

The overall power of this test is

$1-\beta = P\left(\bigcap_{k=1}^K \{Z_k > z_\alpha\}\,\Big|\, H_1\right)$

where $$z_\alpha$$ is the $$(1-\alpha)$$-quantile of the standard normal distribution and the overall power is referred to as conjunctive power [3, 10].

Next, we demonstrate how to calculate the sample size for a trial with two co-primary endpoints with known covariance.

• K = 2, number of co-primary endpoints
• delta = c(0.25, 0.4), expected effect size
• either Sigma or rho and SD must be specified
• Sigma = matrix(c(1, 0.8, 0.8, 1), nrow = 2), known covariance matrix
• rho = 0.8, known correlation
• SD = c(1,1), known standard deviations
• sig.level = 0.025, significance level
• power = 0.80, intended power
• n = ?
library(mpe)
## Loading required package: mvtnorm
Sigma <- matrix(c(1, 0.8, 0.8, 1), nrow = 2)
power.known.var(K = 2, delta = c(0.25, 0.4), Sigma = Sigma, sig.level = 0.025, power = 0.8)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 251.2079
##           delta = 0.25, 0.40
##              SD = 1, 1
##             rho = 0.8
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.8
## [2,]  0.8  1.0
##
## NOTE: n is number in *each* group
## equivalent: known SDs and correlation rho
power.known.var(K = 2, delta = c(0.25, 0.4), SD = c(1,1), rho = 0.8, sig.level = 0.025,
power = 0.8)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 251.2079
##           delta = 0.25, 0.40
##              SD = 1, 1
##             rho = 0.8
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.8
## [2,]  0.8  1.0
##
## NOTE: n is number in *each* group

We obtain a sample size of n = 252 which is the sample size per group; that is, the total sample size required is 2n = 504.

On the other hand, we can also calculate the power for a given sample size. In the above example with two multiple co-primary endpoints with known covariance we get.

• K = 2, number of co-primary endpoints
• delta = c(0.25, 0.4), expected effect size
• Sigma = matrix(c(1, 0.8, 0.8, 1), nrow = 2), known covariance matrix
• rho = 0.8, known correlation
• SD = c(1,1), known standard deviations
• sig.level = 0.025, significance level
• n = 252, sample size per group
• power = ?
power.known.var(K = 2, n = 252, delta = c(0.25,0.4), Sigma=Sigma, sig.level = 0.025)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 252
##           delta = 0.25, 0.40
##              SD = 1, 1
##             rho = 0.8
##       sig.level = 0.025
##           power = 0.8012348
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.8
## [2,]  0.8  1.0
##
## NOTE: n is number in *each* group
## equivalent: known SDs and correlation rho
power.known.var(K = 2, n = 252, delta = c(0.25, 0.4), SD = c(1,1), rho = 0.8,
sig.level = 0.025)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 252
##           delta = 0.25, 0.40
##              SD = 1, 1
##             rho = 0.8
##       sig.level = 0.025
##           power = 0.8012348
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.8
## [2,]  0.8  1.0
##
## NOTE: n is number in *each* group

The computed power is $$80.1\%$$.

Furthermore, we can perform the corresponding multivariate intersection-union z-test by applying our function mpe.z.test. Here we use simulated data for the demonstration.

## effect size
delta <- c(0.25, 0.5)
## covariance matrix
Sigma <- matrix(c(1, 0.75, 0.75, 1), ncol = 2)
## sample size
n <- 50
## generate random data from multivariate normal distributions
X <- rmvnorm(n=n, mean = delta, sigma = Sigma)
Y <- rmvnorm(n=n, mean = rep(0, length(delta)), sigma = Sigma)
## perform multivariate z-test
mpe.z.test(X = X, Y = Y, Sigma = Sigma)
##
##  Intersection-union z-test
##
## data:  x and y
## z = 0.43789, p-value = 0.3307
## alternative hypothesis:  true difference in means is larger than 0 for all endpoints
## 97.5 percent confidence intervals:
##           0.025   1
## EP.1 -0.3044143 Inf
## EP.2  0.0298539 Inf
## sample estimates:
##       EP.1       EP.2
## 0.08757852 0.42184670

### 2.2. Unknown Variance

In this section, we give the formulas from Chapter 2 of [12] where we assume the covariance as unknown. Let $$D=(D_{1},\ldots,D_{K})^T$$ with $$D_{K}=\frac{\overline{Y_{T_k}} - \overline{Y_{C_k}}} {\sigma_{k}}$$ be the effect sizes for the $$K$$ endpoints. Then, $$\sqrt{kn}{D}$$ is distributed as a k-variate normal distribution with mean vector $$\sqrt{kn}{\delta}$$ and covariance matrix $$\rho_Z$$; i.e., $$\sqrt{kn}{D}\sim N_k(\sqrt{kn}{\delta},\rho_z)$$.

The hypotheses given above in Sec. 2.1 can be tested using a multivariate intersection-union t-test, which is implemented in function mpe.t.test. The test statistic is

$T_k = \frac{\sqrt{n}({\overline{Y_{T_k}}-\overline{Y_{C_k}}})}{\sqrt{2}{s_k}}, \quad k = 1,2,\ldots, K$

where $$n$$ is the sample size per group (i.e., we assume a balanced design), and $$s_{k}$$ is the estimate of the pooled standard deviation; $$\overline{Y_{T_k}}$$ and $$\overline{Y_{C_k}}$$ are the respective sample means.

$1-\beta = P\left(\bigcap_{k=1}^K \{T_k > t_{\alpha,{2n-2}\}},|\, H_1\right)$

where $$t_{\alpha,{2n-2}}$$ is the $$(1-\alpha)$$-quantile of the t-distribution with $$2n-2$$ degrees of freedom.

Now, we demonstrate how to calculate the sample size for a trial with two co-primary endpoints with unknown covariance. Here, we follow three steps to determine the sample size.

• Step 1: As we need starting values for our algorithm that computes the sample size in this case, we first act as if the covariance would be known and compute the sample size by applying our function power.known.var.

• Step 2: The resulting value of n is considered as lower bound for the sample size in case of unknown covariance and is used as min.n in function power.unkown.var. Moreover, we specify a reasonable max.n which must be larger than min.n.

• Step 3: Finally, by using the arguments from the step 2, we can compute the sample size for the situation with unknown covariance.

###### Step 1:
• K= 2, number of co-primary endpoints
• delta = c(0.5, 0.4), expected effect size
• either Sigma or rho and SD must be given in the function
• Sigma = c(1, 0.5,0.5, 1), “known” covariance matrix
• rho = 0.5, “known” correlation
• SD = c(1,1), “known” standard deviation
• sig.level = 0.025, significance level
• power = 0.80, intended power.
Sigma <- matrix(c(1, 0.5, 0.5, 1), nrow = 2)
power.known.var(K = 2, delta = c(0.5, 0.4), Sigma = Sigma, sig.level = 0.025, power = 0.8)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 104.0511
##           delta = 0.5, 0.4
##              SD = 1, 1
##             rho = 0.5
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.5
## [2,]  0.5  1.0
##
## NOTE: n is number in *each* group
###### Step 2:

The resulting value of n, which is 105, is used as min.n, and max.n must be larger then min.n so we try 120.

###### Step 3:
• K= 2, number of co-primary endpoints
• delta = c(0.5, 0.4), expected effect size
• either Sigma or rho and SD must be given in the function
• Sigma = c(1, 0.5,0.5, 1), unknown covariance matrix
• rho = 0.5, unknown correlation
• SD = c(1,1), unknown standard deviation
• sig.level = 0.025, significance level
• power = 0.80,intended power
• min.n = 105, value of sample size with known variance
• max.n = 120, assuming a number which is greater then min.n
• n = ? ,
Sigma <- matrix(c(1, 0.5, 0.5, 1), nrow = 2)
power.unknown.var(K = 2, delta = c(0.5, 0.4), Sigma = Sigma, sig.level = 0.025, power = 0.8,
min.n = 105, max.n = 120)
## Current precision:    -0.005183346
## Current precision:    0.05194197
## Current precision:    0.001226959
## Current precision:    0.0007455071
## Current precision:    -0.002554141
## Current precision:    -0.0002106245
## Current precision:    -5.013412e-05
## Current precision:    -0.0001801196
## Current precision:    -0.0001010087
## Current precision:    -0.0002945284
## Current precision:    0.0004427812
## Current precision:    -8.351655e-05
## Current precision:    0.0001445749
## Current precision:    -5.810938e-05
## Current precision:    0.0004241819
## Current precision:    -1.164787e-05
## Current precision:    7.222991e-05
## Current precision:    1.375664e-05
## Current precision:    -0.0001366906
##
##  Power calculation for multiple co-primary endpoints (covariance unknown)
##
##               n = 106.0833
##           delta = 0.5, 0.4
##              SD = 1, 1
##             rho = 0.5
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.5
## [2,]  0.5  1.0
##
## NOTE: n is number in *each* group
##equivalent: known SDs and correlation rho
Sigma <- matrix(c(1, 0.5, 0.5, 1), nrow = 2)
power.unknown.var(K = 2, delta = c(0.5, 0.4), rho = 0.5, SD = c(1,1), sig.level = 0.025,
power = 0.8, min.n = 105, max.n = 120)
## Current precision:    -0.004357514
## Current precision:    0.05272392
## Current precision:    0.0002567645
## Current precision:    0.0002344984
## Current precision:    -0.002245868
## Current precision:    -0.0003734959
## Current precision:    -1.787234e-05
## Current precision:    -0.0003770132
## Current precision:    -0.0004058011
## Current precision:    0.0001579714
## Current precision:    -9.585282e-05
## Current precision:    0.0003188437
## Current precision:    1.869084e-05
## Current precision:    1.971149e-05
## Current precision:    0.0001344951
## Current precision:    0.0002442461
##
##  Power calculation for multiple co-primary endpoints (covariance unknown)
##
##               n = 106.0751
##           delta = 0.5, 0.4
##              SD = 1, 1
##             rho = 0.5
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.5
## [2,]  0.5  1.0
##
## NOTE: n is number in *each* group

We obtain a sample size of n = 107 which is the sample size per group; that is, the total sample size required is 2n = 214. The results vary a little bit as the calculation is based on M simulations (default: M = 10000).

Next, we calculate the power for a given sample size using the following setup.

• K= 2, number of co-primary endpoints
• delta = c(0.5, 0.4), expected effect size
• either Sigma or rho and SD must be given in the function
• Sigma = c(1, 0.5, 0.5, 1), expected covariance matrix
• rho = 0.5, expected correlation
• SD = c(1,1), expected standard deviations
• sig.level = 0.025, significance level
• n = 107, sample size per group
• power = ?, calcuated power
power.unknown.var(K = 2, n = 107, delta = c(0.5,0.4), Sigma = matrix(c(1, 0.5,0.5, 1), nrow=2),
sig.level = 0.025)
##
##  Power calculation for multiple co-primary endpoints (covariance unknown)
##
##               n = 107
##           delta = 0.5, 0.4
##              SD = 1, 1
##             rho = 0.5
##       sig.level = 0.025
##           power = 0.8035906
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.5
## [2,]  0.5  1.0
##
## NOTE: n is number in *each* group

The computed power is about $$80.3\%$$.

Moreover, we perform the corresponding intersection-union t-test by using simulated data and applying our function mpe.t.test

## effect size
delta <- c(0.5, 0.4)
## covariance matrix
Sigma <- matrix(c(1, 0.5, 0.5, 1), ncol = 2)
## sample size
n <- 106
## generate random data from multivariate normal distributions
X <- rmvnorm(n=n, mean = delta, sigma = Sigma)
Y <- rmvnorm(n=n, mean = rep(0, length(delta)), sigma = Sigma)
## perform multivariate t-test
mpe.t.test(X = X, Y = Y)
##
##  Intersection-union t-test
##
## data:  x and y
## t = 2.5803, df = 210, p-value = 0.01055
## alternative hypothesis:  true difference in means is larger than 0 for all endpoints
## 97.5 percent confidence intervals:
##            0.025         1
## EDP.1 0.23434853 0.8372358
## EDP.2 0.04433422 0.6646603
## sample estimates:
##               X          Y
## EDP.1 0.5520301 0.01623797
## EDP.2 0.4055822 0.05108497

## 3. Multiple Primary Endpoints

In this case, the trial is designed to find a significant difference for at least one endpoint. For example, in congestive heart failure trials like VEST [6] and
MERIT [7] two primary endpoints are considered [5]. The primary endpoints are

1. All-cause mortality
2. Hospitalization for heart failure

By increasing the number of endpoints the type I error increases. Hence, in order to control the type I error, one can apply the conservative Bonferroni correction [1, 10]. Here, we distribute $$\alpha$$ equally over all endpoints; i.e., $$\alpha_k = \alpha/K (k = 1,...K)$$.

As we are considering a superiority trial, the superiority of the test intervention over control is given if and only if $$µ_{T_k} - µ_{C_k} > 0$$ for at least one $$k = 1,2.....K$$. In statistical testing, the null hypothesis is rejected if and only if at least one of the $$K$$ primary endpoints is significant at $$\alpha_k$$

$$H_0 : µ_{T_k} - µ_{C_k} <= 0$$, for all $$k$$,

$$H_1 : µ_{T_k} - µ_{C_k} > 0$$, for at least one $$k$$.

As we are assuming a known covariance, the hypotheses can be tested using a multivariate union-intersection z-test.

$1-\beta = P\left(\bigcup_{k=1}^K \{Z_k > z_\frac\alpha K\}\,\Big|\, H_1\right)$

The overall power is also known as disjunctive power [3, 10].

We now demonstrate how to calculate the sample size for a trial with two multiple primary endpoints with known covariance.

• K = 2, number of primary endpoints
• delta = c(0.20,0.30), expected effect size
• either Sigma or rho and SD must be given in the function
• Sigma = c(1, 0.3,0.3, 1), known covariance matrix
• rho = 0.3, correlation
• SD = c(1,1), known standard deviation
• power = 0.8, intended power
• n = ?
atleast.one.endpoint(K = 2, delta = c(0.20,0.30),  Sigma = matrix(c(1, 0.3, 0.3, 1), nrow = 2),
power = 0.8, sig.level = 0.025)
##
##  Power calculation for multiple primary endpoints for at least one endpoint
##
##               n = 146.6651
##           delta = 0.2, 0.3
##              SD = 1, 1
##             rho = 0.3
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.3
## [2,]  0.3  1.0
##
## NOTE: n is number in *each* group
##equivalent: known SDs and correlation rho
atleast.one.endpoint(K = 2, delta = c(0.20, 0.30), SD = c(1,1), rho = 0.3,  power = 0.8)
##
##  Power calculation for multiple primary endpoints for at least one endpoint
##
##               n = 146.6651
##           delta = 0.2, 0.3
##              SD = 1, 1
##             rho = 0.3
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.3
## [2,]  0.3  1.0
##
## NOTE: n is number in *each* group

We obtain a sample size of n = 147 which is the sample size per group; that is, the total sample size required is 2n = 294.

Later, we calculate the power for a given sample size using the following setup.

• K = 2, number of primary endpoints
• delta = c(0.20,0.30), expected effect size
• either Sigma or rho and SD must be given in the function
• Sigma = c(1, 0.3,0.3, 1), known covariance matrix
• rho = 0.3, known correlation
• SD = c(1,1), known standard deviation
• n = 147, sample size per group
• power = ?
atleast.one.endpoint(K = 2, n = 147, delta = c(0.20,0.30),
Sigma = matrix(c(1, 0.3, 0.3, 1), nrow = 2))
##
##  Power calculation for multiple primary endpoints for at least one endpoint
##
##               n = 147
##           delta = 0.2, 0.3
##              SD = 1, 1
##             rho = 0.3
##       sig.level = 0.025
##           power = 0.8008328
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.3
## [2,]  0.3  1.0
##
## NOTE: n is number in *each* group

The computed power is $$80.1\%$$.

## 4. Applications

### 4.1. Multiple co-primary endpoints with known covariance

In Alzheimer’s Disease (AD) clinical trials, ADAS-cog (Alzheimer’s Disease Assessment Scale - cognitive Sub-Scale) and CIBIC-plus (Clinicians Interview Based Impression of Change - plus care give) are used as co-primary endpoints. In a 24 week double blinded, placebo controlled trial of donepezil in patients with AD [9], in which the standardized effect size of ADAS-cog and CIBIC-plus are given as 0.47 and 0.48 and known correlations of the two endpoints are $$\rho_z$$ = 0.0, 0.3, 0.5, 0.8 at a significance level of 0.025 with power = 0.80, the sample sizes can be calculated as follows

• K = 2, number of co-primary endpoints
• delta = c(0.47, 0.48), expected effect size
• either Sigma or rho and SD must be specified
• Sigma = matrix(c(1, rho, rho, 1), nrow = 2), known covariance matrix
• where rho = 0.0, or 0.3, or 0.5, or 0.8, known correlation
• SD = c(1, 1), known standard deviations
• sig.level = 0.025, significance level
• power = 0.80, intended power
• n = ?
## correlation = 0.0,0.3,0.5,0.8
power.known.var(K = 2,delta = c(0.47, 0.48), Sigma = matrix(c(1, 0.0, 0.0, 1), nrow = 2),
sig.level = 0.025, power = 0.8)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 91.40751
##           delta = 0.47, 0.48
##              SD = 1, 1
##             rho = 0
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]    1    0
## [2,]    0    1
##
## NOTE: n is number in *each* group
power.known.var(K= 2,delta = c(0.47, 0.48), Sigma = matrix(c(1, 0.3, 0.3, 1), nrow = 2),
sig.level = 0.025, power = 0.8)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 89.11173
##           delta = 0.47, 0.48
##              SD = 1, 1
##             rho = 0.3
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.3
## [2,]  0.3  1.0
##
## NOTE: n is number in *each* group
power.known.var(K = 2,delta = c(0.47, 0.48), Sigma = matrix(c(1, 0.5, 0.5, 1), nrow = 2),
sig.level = 0.025, power = 0.8)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 86.81057
##           delta = 0.47, 0.48
##              SD = 1, 1
##             rho = 0.5
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.5
## [2,]  0.5  1.0
##
## NOTE: n is number in *each* group
power.known.var(K = 2, delta = c(0.47, 0.48), Sigma = matrix(c(1, 0.8, 0.8, 1), nrow = 2),
sig.level = 0.025, power = 0.8)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 81.25548
##           delta = 0.47, 0.48
##              SD = 1, 1
##             rho = 0.8
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.8
## [2,]  0.8  1.0
##
## NOTE: n is number in *each* group

The sample sizes obtained at $$\rho_z$$ = 0.0, 0.3, 0.5, 0.8 are n = 92, 90, 87, 82 for each group. That is, total sample sizes required are 2n= 184, 180, 174, 164 and we observe that the sample size decreases with increasing correlation.

### 4.2. Multiple co-primary endpoints with unknown covariance

We illustrate this by considering again a AD’s clinical trial with the three co-primary endpoints SIB-score (an objective cognitive test), ADCS-ADL severity score (self-care and activities of daily living) and the CGI score (Clinical Global Impressions). The standardized effect size changes from baseline to six months are assumed as 0.36, 0.30, 0.26. The unknown correlations among the three endpoints are assumed to be identical at $$\rho_z$$ = 0.3. For sig.level = 0.025 and power = 0.80, the sample size can be calculated as follows

###### step 1:

Firstly, we assume the covariance as known and compute the sample size

• K = 3, number of co-primary endpoints
• delta = c(0.36, 0.30, 0.26), expected effect sizes
• either Sigma or rho and SD must be given in the function
• Sigma = matrix(c(1, 0.3, 0.3, 0.3, 1, 0.3, 0.3, 0.3, 1), nrow = 3), “known” covariance matrix
• rho = c(0.3, 0.3, 0.3), “known” correlations
• SD = c(1, 1, 1), “known” standard deviations
• power = 0.8, intended power
• n = ?
power.known.var(K = 3, delta = c(0.36, 0.30, 0.26),
Sigma = matrix(c(1, 0.3, 0.3, 0.3, 1, 0.3, 0.3, 0.3, 1), nrow = 3),
sig.level = 0.025, power = 0.8)
##
##  Power calculation for multiple co-primary endpoints (covariance known)
##
##               n = 267.2319
##           delta = 0.36, 0.30, 0.26
##              SD = 1, 1, 1
##             rho = 0.3, 0.3, 0.3
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2] [,3]
## [1,]  1.0  0.3  0.3
## [2,]  0.3  1.0  0.3
## [3,]  0.3  0.3  1.0
##
## NOTE: n is number in *each* group
###### Step 2:

The value of n, which is 268, is used as min.n and max.n must be larger then min.n so we try 300.

###### step 3:

Now, we can compute the sample size with unknown covariance

• K = 3, number of co-primary endpoints
• delta = c(0.36, 0.30, 0.26), expected effect size
• either Sigma or rho and SD must be given in the function
• Sigma = matrix(c(1, 0.3, 0.3, 0.3, 1, 0.3, 0.3, 0.3, 1), nrow = 3), expected covariance matrix
• rho = c(0.3, 0.3, 0.3), expected correlation
• SD = c(1, 1, 1), expected standard deviations
• power = 0.8, intended power
• min.n = 268, value of sample size with known variance
• max.n = 300, assuming a number which is greater then min.n
• n = ?
power.unknown.var(K = 3, delta = c(0.36, 0.30, 0.26),
Sigma = matrix(c(1, 0.3, 0.3, 0.3, 1, 0.3, 0.3, 0.3, 1), nrow = 3),
sig.level = 0.025, power = 0.8, min.n = 268, max.n = 300)
## Current precision:    -0.002426902
## Current precision:    0.05137849
## Current precision:    0.000169306
## Current precision:    0.0002508998
## Current precision:    -0.0008288301
## Current precision:    -0.0002253579
## Current precision:    7.495852e-05
## Current precision:    0.0002154162
## Current precision:    0.0002540841
## Current precision:    -0.000154963
## Current precision:    7.777393e-05
## Current precision:    0.0001307429
## Current precision:    0.000208311
## Current precision:    4.244982e-06
## Current precision:    -5.330467e-05
## Current precision:    0.0002814764
##
##  Power calculation for multiple co-primary endpoints (covariance unknown)
##
##               n = 269.2066
##           delta = 0.36, 0.30, 0.26
##              SD = 1, 1, 1
##             rho = 0.3, 0.3, 0.3
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2] [,3]
## [1,]  1.0  0.3  0.3
## [2,]  0.3  1.0  0.3
## [3,]  0.3  0.3  1.0
##
## NOTE: n is number in *each* group

We obtain a sample size of n = 270 which is the sample size per group; that is, the total sample size required is 2n = 540.

### 4.3. Multiple primary endpoints

Here, by considering the example of the Alzheimer’s Disease (AD) clinical trial discussed in Sec. 4.1, we illustrate the sample size calculations for multiple primary endpoints. The standardized effect sizes for ADAS-cog and CIBIC-plus are assumed as 0.47 and 0.48 and the correlation of the two endpoints is assumed to be known as $$\rho_z$$ = 0.0, 0.3, 0.8 at a significance level of 0.025 with power = 0.80.

• K = 2, number of primary endpoints
• delta = c(0.47, 0.48), expected effect size
• either Sigma or rho and SD must be specified
• Sigma = matrix(c(1, rho, rho, 1), nrow = 2), known covariance matrix
• where rho = 0.0, or 0.3, or 0.5, or 0.8, known correlation
• SD = c(1, 1), known standard deviations
• sig.level = 0.025, significance level
• power = 0.80, intended power
• n = ?
atleast.one.endpoint(K= 2, delta = c(0.47, 0.48), Sigma = matrix(c(1, 0.0, 0.0, 1), nrow = 2),
power = 0.8)
##
##  Power calculation for multiple primary endpoints for at least one endpoint
##
##               n = 38.81217
##           delta = 0.47, 0.48
##              SD = 1, 1
##             rho = 0
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]    1    0
## [2,]    0    1
##
## NOTE: n is number in *each* group
atleast.one.endpoint(K= 2, delta = c(0.47, 0.48), Sigma = matrix(c(1, 0.3, 0.3, 1), nrow = 2),
power = 0.8)
##
##  Power calculation for multiple primary endpoints for at least one endpoint
##
##               n = 44.1185
##           delta = 0.47, 0.48
##              SD = 1, 1
##             rho = 0.3
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.3
## [2,]  0.3  1.0
##
## NOTE: n is number in *each* group
atleast.one.endpoint(K= 2, delta = c(0.47, 0.48), Sigma = matrix(c(1, 0.5, 0.5, 1), nrow = 2),
power = 0.8)
##
##  Power calculation for multiple primary endpoints for at least one endpoint
##
##               n = 48.25827
##           delta = 0.47, 0.48
##              SD = 1, 1
##             rho = 0.5
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.5
## [2,]  0.5  1.0
##
## NOTE: n is number in *each* group
atleast.one.endpoint(K= 2, delta = c(0.47, 0.48), Sigma = matrix(c(1, 0.8, 0.8, 1), nrow = 2),
power = 0.8)
##
##  Power calculation for multiple primary endpoints for at least one endpoint
##
##               n = 56.35982
##           delta = 0.47, 0.48
##              SD = 1, 1
##             rho = 0.8
##       sig.level = 0.025
##           power = 0.8
##
## Sigma =
##      [,1] [,2]
## [1,]  1.0  0.8
## [2,]  0.8  1.0
##
## NOTE: n is number in *each* group

Sample sizes obtained at $$\rho_z$$ = 0.0, 0.3, 0.5, 0.8 are n = 39, 45, 49, 57 for each group. That is, the total sample sizes required are 2n= 78, 90, 98, 104. Hence, the sample size increases with increasing correlation.

## 5. Summary

In clinical trials, the use of more than two primary endpoints is often necessary nowadays. Here, the correlation plays a crucial role which creates a quite complicated situation and makes it challenging to calculate the sample size and to estimate power. Hence, in order to make this accessible, we follow the book [12] and implemented our package mpe with the functions introduced above. One can use it to calculate sample size and power for multiple (co-)primary endpoints and we hope that it will be useful for statisticians and practicians.

## 6. References

1. Alex Dmitrenko, Ajit C. Tamhane, Frank Bret, Multiple Testing Problems In Pharmaceutical statistics. Chapman & Hall/CRC Biostatistics Series ISBN 9781584889847

2. Berger, R.L. (1982). Multiparameter hypothesis testing and acceptance sampling. Technometrics 24, 295-300

3. F.Bretz, T. Hothorn, and P. Westfall. Multiple Comparisons Using R. 2010 by Chapman and Hall/CRC ISBN 9781584885740

4. Food and Drug Administration (FDA 2012). Guidance for Industry Irritable Bowel Syndrome — Clinical Evaluation of Drugs for Treatment.

5. Gong J, Pinheiro JC, DeMets DL, Estimating significance level and power comparisons for testing multiple endpoints in clinical trials.Control Clin Trials. Control Clin Trials. 2000 Aug;21(4):313-29

6. J.N. Cohn, S.O. Goldstein, B.H. Greenberg, et al, A dose-dependent increase in mortality with vesnarinone among patients with severe heart failure. N Engl J Med, 339 (1998), pp. 1810–1816

7. MERIT-HF Study Group, Effect of metoprolol CR/XL in chronic heart failure: Metoprolol CR/XL randomized intervention trial in congestive heart failure. Lancet, 353 (1999), pp. 2001–2007

8. N. L. Johnson and S. Kotz (1972). Distributions in Statistics—Continuous Multivariate Distributions, New York: John Wiley & Son

9. Rogers SL, Farlow MR, Doody RS, Mohs R, Friedhoff LT. A 24-week, double-blind, placebo-controlled trial of donepezil in patients with Alzheimer’s disease. Donepezil Study Group. Neurology. 1998 Jan;50(1):136-45

10. Senn S, Bretz F, Power and sample size when multiple endpoints are considered. Pharm Stat. 2007 Jul-Sep;6(3):161-70

11. Sozu T, Sugimoto T, Hamasaki T (2011), Sample Size Determination in Superiority Clinical Trials With Multiple Co-Primary Correlated Endpoints. J Biopharm Stat. 2011 Jul;21(4):650-68

12. Sozu T, Sugimoto T, Hamasaki T, Evans S.R., Sample Size Determination in Clinical Trials with Multiple Endpoints. ISBN 978-3-319-22005-5