1 00:00:05,939 --> 00:00:09,776 >> GOOD MORNING, WELCOME TO 2 00:00:09,843 --> 00:00:13,980 THE NIHCD SEMINAR SERIES, I AM 3 00:00:14,047 --> 00:00:16,649 DOCTOR ALANAFORD AND WILL BE 4 00:00:16,716 --> 00:00:19,686 STANDING IN FOR. 5 00:00:19,753 --> 00:00:20,253 [INDISCERNIBLE] 6 00:00:20,320 --> 00:00:21,821 -- BUT BECAUSE I HAVE THE 7 00:00:21,888 --> 00:00:27,694 PLEASURE OF INTRODUCING MY 8 00:00:27,761 --> 00:00:28,928 COLLEAGUE, Dr. STRESS. 9 00:00:28,995 --> 00:00:31,998 Dr. STRESS IS A 10 00:00:32,065 --> 00:00:39,239 EPIDEMIOLOGIST AND STAFF 11 00:00:39,305 --> 00:00:44,377 SCIENTIST AT NIMHCD -- 12 00:00:44,444 --> 00:00:45,612 [INDISCERNIBLE] 13 00:00:45,678 --> 00:00:47,447 Dr. STRAPH WAS ALSO THE 14 00:00:47,514 --> 00:00:49,849 REPRESENTATIVE FOR THE GLOBAL 15 00:00:49,916 --> 00:00:51,451 DISEASE COLLABORATION WHICH IS 16 00:00:51,518 --> 00:00:54,888 TASKED WITH MORTALITY RATES 17 00:00:54,954 --> 00:01:05,498 AND QUALITY OF LIFE FOR RACE 18 00:01:05,865 --> 00:01:09,502 AND ETHNICITY. 19 00:01:09,569 --> 00:01:12,238 Dr. STOPH IS INTERESTED IN 20 00:01:12,305 --> 00:01:16,943 EXPLORING IMPACT OF BIAS IN 21 00:01:17,010 --> 00:01:18,745 LARGE COMPUTATIONAL DATASETS 22 00:01:18,812 --> 00:01:22,081 AND MAKING THE INFORMATION 23 00:01:22,148 --> 00:01:27,954 AVAILABLE TO RESEARCHERS. 24 00:01:28,021 --> 00:01:33,193 Dr. STRAPH RECEIVED HER 25 00:01:33,259 --> 00:01:35,462 PH.D. AT UNIVERSITY OF NORTH 26 00:01:35,528 --> 00:01:36,663 CAROLINA AT CHAPEL HILL. 27 00:01:36,729 --> 00:01:38,832 PRIOR TO THAT, SHE WAS 28 00:01:38,898 --> 00:01:39,933 ASSISTANT PROFESSOR AT 29 00:01:39,999 --> 00:01:44,771 UNIVERSITY OF NORTH CAROLINA 30 00:01:44,838 --> 00:01:45,238 AT CHAPEL HILL. 31 00:01:45,305 --> 00:01:50,577 IN 1993, Dr. STRAPH RECEIVED 32 00:01:50,643 --> 00:01:51,478 THE WOMEN'S INNOVATION AWARD 33 00:01:51,544 --> 00:01:53,880 AND LEADER OF THE AWARDS IN 34 00:01:53,947 --> 00:01:55,882 THE DIVISION. 35 00:01:55,949 --> 00:01:59,352 I AM LOOKING FORWARD TO Dr. 36 00:01:59,419 --> 00:02:03,857 STRAPH'S TALK AND Q&A SESSION 37 00:02:03,923 --> 00:02:06,893 AND AS A REMINDER, PLEASE POST 38 00:02:06,960 --> 00:02:08,761 YOUR QUESTION ON THE SCREEN. 39 00:02:08,828 --> 00:02:11,164 >> THANK YOU FOR THE NICE 40 00:02:11,231 --> 00:02:17,704 INTRODUCTION, LET ME SHARE MY 41 00:02:17,770 --> 00:02:19,405 SCREEN. 42 00:02:19,472 --> 00:02:28,448 OKAY, SO AS ALANA MENTIONED, 43 00:02:28,515 --> 00:02:38,391 MY NAME IS PAULA STRASSLE AND 44 00:02:38,458 --> 00:02:42,762 I AM TALKING ABOUT USING 45 00:02:42,829 --> 00:02:44,931 OBSERVATIONAL DATA TO ADDRESS 46 00:02:44,998 --> 00:02:48,334 DISPARITIES IN CLINICAL TRIALS 47 00:02:48,401 --> 00:02:49,602 THAT WE SEE. 48 00:02:49,669 --> 00:02:51,638 HERE ARE MY DISCLAIMERS AND 49 00:02:51,704 --> 00:02:54,741 THEN JUST AS A QUICK AGENDA, I 50 00:02:54,807 --> 00:03:00,046 WILL TALK ABOUT DISPARITIES IN 51 00:03:00,113 --> 00:03:03,249 CLINICAL TRIAL PARTICIPATIONS, 52 00:03:03,316 --> 00:03:07,487 THE OBSERVATIONAL BIASES IN 53 00:03:07,554 --> 00:03:08,588 STUDIES, FOCUSING ON 54 00:03:08,655 --> 00:03:10,290 DISPARITIES AS THE TITLE 55 00:03:10,356 --> 00:03:15,962 SUGGESTS AND THEN TALKING 56 00:03:16,029 --> 00:03:17,463 ABOUT THE OBSERVATIONAL 57 00:03:17,530 --> 00:03:19,999 STUDIES IN A APPROACHABLE WAY 58 00:03:20,066 --> 00:03:21,367 AND HOPEFULLY GETTING MORE 59 00:03:21,434 --> 00:03:26,205 USERS IN THIS I WOULD SAY NEW 60 00:03:26,272 --> 00:03:27,307 METHOD IN EPIDEMIOLOGY. 61 00:03:27,373 --> 00:03:28,441 PARTICIPATION CLINICAL TRIALS 62 00:03:28,508 --> 00:03:31,077 IS LOW BUT ESPECIALLY IN 63 00:03:31,144 --> 00:03:33,146 CANCER CLINICAL TRIALS, IT IS 64 00:03:33,212 --> 00:03:34,213 ESPECIALLY LOW. 65 00:03:34,280 --> 00:03:36,382 ONLY 2 TO 3 PERCENT OF ADULT 66 00:03:36,449 --> 00:03:38,184 CANCER PATIENTS PARTICIPATE IN 67 00:03:38,251 --> 00:03:39,385 A CLINICAL TRIAL DURING THEIR 68 00:03:39,452 --> 00:03:41,321 TREATMENT AND AS YOU CAN SEE 69 00:03:41,387 --> 00:03:46,993 IN THIS FIGURE ON THE RIGHT, 70 00:03:47,060 --> 00:03:49,929 BY THIS REVIEW, THEY IDENTIFY 71 00:03:49,996 --> 00:03:51,931 SEVERAL BARRIERS TO 72 00:03:51,998 --> 00:03:53,366 PARTICIPATE IN CLINICAL TRIALS 73 00:03:53,433 --> 00:03:55,735 FOR CANCER PATIENTS WITH THE 74 00:03:55,802 --> 00:03:57,370 BIGGEST ONE BEING STRUCTURAL 75 00:03:57,437 --> 00:03:59,772 AND THE FACT THAT THE MAJORITY 76 00:03:59,839 --> 00:04:01,140 OF PLACES AND CENTERS FOR 77 00:04:01,207 --> 00:04:02,642 INDIVIDUALS GET TREATED FOR 78 00:04:02,709 --> 00:04:04,177 CANCER, THEY DON'T PARTICIPATE 79 00:04:04,243 --> 00:04:05,745 IN TRIALS, DON'T HAVE TRIALS 80 00:04:05,812 --> 00:04:07,814 AVAILABLE AT THE CENTERS SO 81 00:04:07,880 --> 00:04:13,119 YOU KNOW THERE JUST ISN'T ANY 82 00:04:13,186 --> 00:04:15,154 RESPECTABILITY IN THE TRIALS. 83 00:04:15,221 --> 00:04:17,256 THE SECOND BARRIER IS CLINICAL 84 00:04:17,323 --> 00:04:19,792 IN THAT CLINICAL TRIALS 85 00:04:19,859 --> 00:04:21,694 USUALLY HAVE 86 00:04:21,761 --> 00:04:24,030 INCLUSION/EXCLUSION CRITERIA 87 00:04:24,097 --> 00:04:30,503 WHICH MAKES PATIENTS 88 00:04:30,570 --> 00:04:36,009 INELIGIBLE LIKE PATIENTS WITH 89 00:04:36,075 --> 00:04:36,609 COMORBIDITIES, ADVANCED 90 00:04:36,676 --> 00:04:38,611 CANCER, A LOT OF THESE THINGS 91 00:04:38,678 --> 00:04:41,047 CAN MAKE YOU INELIGIBLE FOR 92 00:04:41,114 --> 00:04:42,215 THESE TRIALS EVEN WHEN YOU 93 00:04:42,281 --> 00:04:43,683 HAVE ACCESS TO THEM. 94 00:04:43,750 --> 00:04:48,354 AND IF YOU CAN IMAGINE, THE 95 00:04:48,421 --> 00:04:50,657 STRUCTURAL AND CLINICAL 96 00:04:50,723 --> 00:04:51,824 OBSERVATIONAL BARRIERS ARE 97 00:04:51,891 --> 00:04:56,929 MORE LIKELY TO OCCUR IN ETHNIC 98 00:04:56,996 --> 00:04:58,998 MINORITIES AND WITH THESE 99 00:04:59,065 --> 00:05:00,933 PATIENTS BEING UNDER 100 00:05:01,000 --> 00:05:03,670 REPRESENTED IN CANCER CLINICAL 101 00:05:03,736 --> 00:05:04,971 TRIALS BUT OVERALL IN ALL 102 00:05:05,038 --> 00:05:06,472 CLINICAL TRIALS AND AS YOU CAN 103 00:05:06,539 --> 00:05:08,975 SEE FROM THIS FIGURE, BLACK 104 00:05:09,042 --> 00:05:11,044 POPULATIONS ARE UNDER 105 00:05:11,110 --> 00:05:13,479 REPRESENTED IN ENROLLMENT TO 106 00:05:13,546 --> 00:05:14,614 CLINICAL TRIALS COMPARED TO 107 00:05:14,681 --> 00:05:16,215 INCIDENTS OF CANCER AND 108 00:05:16,282 --> 00:05:18,284 MORTALITY RELATED TO CANCER. 109 00:05:18,351 --> 00:05:20,353 AND ALL OF THESE FIGURES FOR 110 00:05:20,420 --> 00:05:22,155 OVERALL CANCER, WHEN WE LOOK 111 00:05:22,221 --> 00:05:24,390 ACROSS ALL OF THE TYPES OF 112 00:05:24,457 --> 00:05:26,059 CANCER AND CANCER SITES, WE 113 00:05:26,125 --> 00:05:28,728 SEE A SIMILAR PICTURE. 114 00:05:28,795 --> 00:05:30,863 TO ASSUME IN ON ONE PARTICULAR 115 00:05:30,930 --> 00:05:33,132 KIND OF CANCER USING THAT IN 116 00:05:33,199 --> 00:05:36,569 OUR EXAMPLE LATER, WE CAN SEE 117 00:05:36,636 --> 00:05:38,604 THE MORTALITY BLACK AND 118 00:05:38,671 --> 00:05:39,639 HISPANIC POPULATIONS MAKE 119 00:05:39,706 --> 00:05:42,041 ABOUT 20 PERCENT BUT REPRESENT 120 00:05:42,108 --> 00:05:45,244 ONLY 5 PERCENT OF PARTICIPANTS 121 00:05:45,311 --> 00:05:46,979 IN CLINICAL TRIALS SO THIS CAN 122 00:05:47,046 --> 00:05:51,517 BE A HUGE ISSUE, YOU KNOW, IN 123 00:05:51,584 --> 00:05:53,019 REPRESENTATION. 124 00:05:53,086 --> 00:05:55,288 AND YOU KNOW WHY 125 00:05:55,354 --> 00:05:56,989 REPRESENTATION IN CLINICAL 126 00:05:57,056 --> 00:06:00,359 TRIALS MATTER, WHILE WE REFER 127 00:06:00,426 --> 00:06:02,595 TO IT AS ADVISABILITY, IT IS 128 00:06:02,662 --> 00:06:05,498 CRITICAL ESPECIALLY IF 129 00:06:05,565 --> 00:06:08,668 TREATMENT IS GOING TO BE MADE 130 00:06:08,735 --> 00:06:09,268 ACROSS POPULATIONS. 131 00:06:09,335 --> 00:06:15,475 THERE IS DIFFERENT TYPES OF 132 00:06:15,541 --> 00:06:17,276 CANCER, MECHANISMS WITHIN 133 00:06:17,343 --> 00:06:19,579 CANCER IN THE TRIALS FOR CROSS 134 00:06:19,645 --> 00:06:24,684 TREATMENT AND MAKING SURE 135 00:06:24,751 --> 00:06:26,853 THERE IS EFFECTIVENESS ACROSS 136 00:06:26,919 --> 00:06:28,654 ALL POPULATIONS AND IF THE 137 00:06:28,721 --> 00:06:30,490 TREATMENT IS REALLY HARD TO 138 00:06:30,556 --> 00:06:31,858 ADHERE TO BECAUSE THERE IS A 139 00:06:31,924 --> 00:06:33,059 LOT OF STEPS OR YOU HAVE TO 140 00:06:33,126 --> 00:06:35,294 STAY ON IT FOR A LONG TIME, 141 00:06:35,361 --> 00:06:39,298 YOU KNOW, IN A VERY KIND OF 142 00:06:39,365 --> 00:06:40,433 REGIMENTED CLINICAL TRIAL, YOU 143 00:06:40,500 --> 00:06:43,503 CAN END UP WITH HIGHER 144 00:06:43,569 --> 00:06:45,371 ADHERENCE RATES AND LESS 145 00:06:45,438 --> 00:06:47,607 TREATMENT STRATEGIES DUE TO A 146 00:06:47,673 --> 00:06:49,208 VARIETY OF REASONS THAT YOU 147 00:06:49,275 --> 00:06:53,646 SEE IN THE REAL WORLD THAT END 148 00:06:53,713 --> 00:06:56,315 UP MAKING THE EFFECTIVE 149 00:06:56,382 --> 00:06:58,284 TREATMENTS DIFFER. 150 00:06:58,351 --> 00:07:02,121 NOW WHAT IS ALSO REFERRED TO 151 00:07:02,188 --> 00:07:05,758 AS REAL WORLD DATA CAN END UP 152 00:07:05,825 --> 00:07:06,826 BEING VERY DIFFERENT THAN 153 00:07:06,893 --> 00:07:07,727 TREATMENT EFFECTS. 154 00:07:07,794 --> 00:07:12,198 YOU CAN DO A CROSS ANALYSIS, 155 00:07:12,265 --> 00:07:13,399 DO EFFECTIVE STUDIES WITH 156 00:07:13,466 --> 00:07:16,502 REGARD TO BLACK OR HISPANIC 157 00:07:16,569 --> 00:07:19,472 POPULATIONS OR MORE INCOME 158 00:07:19,539 --> 00:07:20,840 POPULATIONS, POPULATIONS WITH 159 00:07:20,907 --> 00:07:23,376 DISABILITIES, YOU CAN DO ALL 160 00:07:23,442 --> 00:07:25,411 SORTS OF ANALYSIS WITH 161 00:07:25,478 --> 00:07:26,913 TARGETED STUDIES AND AS I 162 00:07:26,979 --> 00:07:28,514 MENTIONED, GET MORE OF A 163 00:07:28,581 --> 00:07:29,248 REPRESENTED POPULATION BECAUSE 164 00:07:29,315 --> 00:07:33,286 YOU DON'T HAVE TO RESTRICT 165 00:07:33,352 --> 00:07:34,987 YOURSELF TO CLINICAL TRIALS 166 00:07:35,054 --> 00:07:39,258 AND CAN USE MORE OF RELAXED 167 00:07:39,325 --> 00:07:41,394 INCLUSION/EXCLUSION CRITERIA. 168 00:07:41,460 --> 00:07:43,629 AND THEN OUTSIDE THE CLINICAL 169 00:07:43,696 --> 00:07:45,665 WORLD BUT ESPECIALLY FOR 170 00:07:45,731 --> 00:07:47,333 HEALTH DISPARITIES, YOU ARE 171 00:07:47,400 --> 00:07:50,403 STILL ABLE TO CONDUCT THESE 172 00:07:50,469 --> 00:07:52,338 CLINICAL STUDIES WHEN CLINICAL 173 00:07:52,405 --> 00:07:55,141 TRIALS WOULD BE UNETHICAL OR 174 00:07:55,208 --> 00:07:55,541 IMPOSSIBLE. 175 00:07:55,608 --> 00:07:58,044 FOR EXAMPLE, WE WOULD NEVER 176 00:07:58,110 --> 00:07:59,745 RANDOMIZE AN INDIVIDUAL IN 177 00:07:59,812 --> 00:08:02,248 POVERTY, AN INDIVIDUAL TO BE 178 00:08:02,315 --> 00:08:04,684 SUBJECT TO STEMMATIC RACISM SO 179 00:08:04,750 --> 00:08:05,585 SOME OF THESE IMPORTANT 180 00:08:05,651 --> 00:08:09,088 QUESTIONS WE ARE ASKING IN 181 00:08:09,155 --> 00:08:09,822 MINORITIES WITH HEALTH 182 00:08:09,889 --> 00:08:11,357 DISPARITIES CAN'T BE ANSWERED 183 00:08:11,424 --> 00:08:12,992 IN CLINICAL TRIALS SO WE'RE 184 00:08:13,059 --> 00:08:16,162 REALLY LEFT WITH TRYING TO 185 00:08:16,229 --> 00:08:17,630 DESIGN SOME OBSERVATIONAL 186 00:08:17,697 --> 00:08:20,766 STUDIES TO ANSWER THESE CAUSAL 187 00:08:20,833 --> 00:08:21,133 QUESTIONS. 188 00:08:21,200 --> 00:08:23,469 SO BECAUSE THOUGH OF THE LACK 189 00:08:23,536 --> 00:08:25,438 OF RANDOMIZATION OF OUR 190 00:08:25,504 --> 00:08:26,472 TREATMENT STRATEGIES, THERE 191 00:08:26,539 --> 00:08:28,941 ARE SEVERAL CHALLENGES USING 192 00:08:29,008 --> 00:08:29,942 REAL WORLD DATA. 193 00:08:30,009 --> 00:08:31,644 HOPEFULLY MOST OF YOU HAVE 194 00:08:31,711 --> 00:08:34,647 HEARD OF CON FOUNDING BEFORE, 195 00:08:34,714 --> 00:08:35,815 MISSING DATA IS OFTEN 196 00:08:35,882 --> 00:08:37,850 SOMETHING THAT CAN OCCUR BUT 197 00:08:37,917 --> 00:08:39,151 THESE THINGS ARE PRETTY 198 00:08:39,218 --> 00:08:39,852 COMMONLY DISCUSSED WHEN 199 00:08:39,919 --> 00:08:41,354 LOOKING AT THE QUALITY OF 200 00:08:41,420 --> 00:08:44,390 STUDIES OR WHEN TRYING TO 201 00:08:44,457 --> 00:08:45,091 DESIGN STUDIES. 202 00:08:45,157 --> 00:08:48,227 SO WHAT WE WILL TALK ABOUT 203 00:08:48,294 --> 00:08:51,764 TODAY IN IMMORTAL TIME BIAS IS 204 00:08:51,831 --> 00:08:53,132 OFTEN OVERLOOKED AND NOT 205 00:08:53,199 --> 00:08:54,533 ADDRESSED AND STAND OUT IN THE 206 00:08:54,600 --> 00:08:55,701 SAMPLES OF OUR WORK. 207 00:08:55,768 --> 00:08:57,169 SO JUST TO MAKE SURE WE ARE 208 00:08:57,236 --> 00:09:00,072 ALL ON THE SAME PAGE, I WILL 209 00:09:00,139 --> 00:09:03,042 BRIEFLY DESCRIBE WHAT IMMORTAL 210 00:09:03,109 --> 00:09:05,811 TIME AND IMMORTAL TIME BIAS 211 00:09:05,878 --> 00:09:06,078 IS. 212 00:09:06,145 --> 00:09:12,084 SO IMMORTAL TIME OCCURS WHEN 213 00:09:12,151 --> 00:09:13,786 THE START OF FOLLOW UP DOES 214 00:09:13,853 --> 00:09:15,554 NOT COINCIDE WITH THE START OF 215 00:09:15,621 --> 00:09:15,922 TREATMENT. 216 00:09:15,988 --> 00:09:17,757 SO YOU GET SOMEONE WHO IS 217 00:09:17,823 --> 00:09:19,258 DIAGNOSED WITH CANCER BUT 218 00:09:19,325 --> 00:09:20,393 WON'T START THEIR TREATMENT 219 00:09:20,459 --> 00:09:24,363 THAT DAY AND MAY END UP 220 00:09:24,430 --> 00:09:25,531 GETTING TREATMENT DAYS, WEEKS 221 00:09:25,598 --> 00:09:26,933 OR EVEN MONTHS AFTER THE 222 00:09:26,999 --> 00:09:27,466 DIAGNOSIS. 223 00:09:27,533 --> 00:09:29,268 SO IN A CLINICAL TRIAL, WE 224 00:09:29,335 --> 00:09:30,670 WOULD HAVE FOUR PATIENTS 225 00:09:30,736 --> 00:09:33,506 DIAGNOSED WITH CANCER AND THEN 226 00:09:33,572 --> 00:09:34,807 RANDOMLY ASSIGN THEM TO 227 00:09:34,874 --> 00:09:36,142 UNDERGO A TREATMENT. 228 00:09:36,208 --> 00:09:38,277 SO FOR THIS EXAMPLE, RED GROUP 229 00:09:38,344 --> 00:09:40,479 IS SURGERY, GREEN GROUP IS NO 230 00:09:40,546 --> 00:09:42,882 SURGERY, SO WE RANDOMLY ASSIGN 231 00:09:42,949 --> 00:09:44,250 THEM TO THEIR TREATMENT GROUPS 232 00:09:44,317 --> 00:09:45,618 AND THEN FOLLOW THEM TO SEE 233 00:09:45,685 --> 00:09:46,352 WHAT HAPPENS. 234 00:09:46,419 --> 00:09:49,322 SO AS WE FOLLOW THEM OVER TIME 235 00:09:49,388 --> 00:09:51,223 WHICH CAN SOMETIMES HAPPEN 236 00:09:51,290 --> 00:09:54,327 WITH PATIENT B HERE, DOESN'T 237 00:09:54,393 --> 00:09:56,262 UNDERGO THE SURGERY THEY WERE 238 00:09:56,329 --> 00:10:00,032 ASSIGNED TO HOWEVER IN MOST 239 00:10:00,099 --> 00:10:01,867 CLINICAL TRIAL STUDIES WHEN 240 00:10:01,934 --> 00:10:03,903 DOING THE ANALYSIS, WE STILL 241 00:10:03,970 --> 00:10:06,539 CONSIDER THAT PERSON IN THE 242 00:10:06,605 --> 00:10:08,341 TREATMENT ARM BECAUSE WE ARE 243 00:10:08,407 --> 00:10:12,611 DOING THE PREANALYSIS SO THE 244 00:10:12,678 --> 00:10:15,281 EFFECTS ARE NOT SEEN IF THEY 245 00:10:15,348 --> 00:10:16,182 DON'T UNDERGO SURGERY. 246 00:10:16,248 --> 00:10:21,420 NOW IN A REAL WORLD 247 00:10:21,487 --> 00:10:22,788 DATASETTING WITH OBSERVATIONAL 248 00:10:22,855 --> 00:10:24,190 DATA, THE PATIENTS HAVE GOT 249 00:10:24,256 --> 00:10:25,491 TEN THE DIAGNOSIS, UNDERGONE 250 00:10:25,558 --> 00:10:26,492 TREATMENT IF THEY WERE GOING 251 00:10:26,559 --> 00:10:29,495 TO AND THEN FOLLOWED FOR A 252 00:10:29,562 --> 00:10:31,397 PRE-SPECIFIED AMOUNT OF TIME 253 00:10:31,464 --> 00:10:34,200 SO IF THEY HAVE 1 YEAR OF 254 00:10:34,266 --> 00:10:37,336 MORTALITY, WE HAVE ONE YEAR OF 255 00:10:37,403 --> 00:10:38,037 DATA ON THEM. 256 00:10:38,104 --> 00:10:41,974 THEN WHAT WE TYPICALLY DO IS 257 00:10:42,041 --> 00:10:43,909 LOOK AT THEM IN THEIR 258 00:10:43,976 --> 00:10:44,410 ASSIGNMENT GROUPS. 259 00:10:44,477 --> 00:10:46,812 SO IF YOU LOOK AT THIS PATIENT 260 00:10:46,879 --> 00:10:48,514 HERE, EVEN THOUGH THEY WOULD 261 00:10:48,581 --> 00:10:52,852 HAVE BEEN BASED ON RANDOMIZED 262 00:10:52,918 --> 00:10:55,588 DESIGN, HERE THE PATIENT 2 263 00:10:55,654 --> 00:10:57,189 DOESN'T UNDERGO SURGERY AND 264 00:10:57,256 --> 00:10:58,791 DOESN'T HAVE PLANNED TREATMENT 265 00:10:58,858 --> 00:11:00,726 BUT ONLY ACTUAL OBSERVED 266 00:11:00,793 --> 00:11:02,428 TREATMENT SO THIS DIFFERENCE 267 00:11:02,495 --> 00:11:04,597 IS WHAT INDUCES THE BIAS. 268 00:11:04,663 --> 00:11:07,033 BUT GETTING BACK TO IMMORTAL 269 00:11:07,099 --> 00:11:09,568 TIME, IT IS THIS TIME HERE 270 00:11:09,635 --> 00:11:10,936 BETWEEN THE ENROLLMENT AND 271 00:11:11,003 --> 00:11:12,872 WHEN THE PERSON GETS TREATED, 272 00:11:12,938 --> 00:11:14,240 THEY ARE CONSIDERED IMMORTAL 273 00:11:14,306 --> 00:11:16,008 BECAUSE IF THEY DIED OR 274 00:11:16,075 --> 00:11:18,744 DROPPED OUT, AND IN THIS CASE, 275 00:11:18,811 --> 00:11:20,880 THIS PERSON DIED BEFORE THEY 276 00:11:20,946 --> 00:11:22,048 COULD RECEIVE TREATMENT, THEY 277 00:11:22,114 --> 00:11:26,419 WOULDN'T BE CONSIDERED IN THE 278 00:11:26,485 --> 00:11:29,388 TREATMENT GROUP AND IT IS THIS 279 00:11:29,455 --> 00:11:31,757 IMMORTAL TIME THAT IS INDUCING 280 00:11:31,824 --> 00:11:34,760 BIAS AND IT CAN BE POTENTIALLY 281 00:11:34,827 --> 00:11:36,429 PROBLEMATIC WHEN IT IS ONLY 282 00:11:36,495 --> 00:11:39,632 PRESENT IN ONE TREATMENT 283 00:11:39,698 --> 00:11:41,667 STRATEGY SO SAY IMMORTAL TIME 284 00:11:41,734 --> 00:11:43,436 WAS PRESENT WHEN YOU UNDERWENT 285 00:11:43,502 --> 00:11:45,371 SURGERY BUT IN ANOTHER GROUP 286 00:11:45,438 --> 00:11:48,340 IT DIDN'T HAPPEN OR IF ONE 287 00:11:48,407 --> 00:11:50,042 PATIENT HAS MORE IMMORTAL TIME 288 00:11:50,109 --> 00:11:52,078 THAN ANOTHER. 289 00:11:52,144 --> 00:11:57,416 SO YOU CAN IMAGINE AFTER THE 290 00:11:57,483 --> 00:11:58,784 DIAGNOSIS AND SURGERY, THEN 291 00:11:58,851 --> 00:12:03,756 THEY HAVE TO GO THROUGH 292 00:12:03,823 --> 00:12:05,624 CHEMOTHERAPY AND MAYBE ANOTHER 293 00:12:05,691 --> 00:12:08,727 SURGERY, THEY CAN HAVE A 294 00:12:08,794 --> 00:12:10,296 LONGER IMMORTAL TIME. 295 00:12:10,362 --> 00:12:11,697 SO THE IMPORTANT QUESTION HERE 296 00:12:11,764 --> 00:12:13,699 IS NOT DOES IT HAPPEN BUT DOES 297 00:12:13,766 --> 00:12:14,800 IT IMPACT OUR RESULTS. 298 00:12:14,867 --> 00:12:17,336 AND THE ANSWER IS ACTUALLY 299 00:12:17,403 --> 00:12:18,104 YES. 300 00:12:18,170 --> 00:12:22,341 SO THIS IS A FUN, I WOULD SAY, 301 00:12:22,408 --> 00:12:24,510 EXAMPLE WHERE IN 2001, SOME 302 00:12:24,577 --> 00:12:32,818 INDIVIDUALS LOOKED AT IF 303 00:12:32,885 --> 00:12:41,327 WINNING AN OSCAR WAS AN IMPACT 304 00:12:41,393 --> 00:12:43,829 IN LONGER SURVIVAL THAN AN 305 00:12:43,896 --> 00:12:45,831 ACTOR WHO DIDN'T. 306 00:12:45,898 --> 00:12:47,299 THIS STUDY SHOWED THAT THERE 307 00:12:47,366 --> 00:12:49,602 WAS A FOUR YEARS' DIFFERENCE 308 00:12:49,668 --> 00:12:51,103 BUT A STUDY CAME OUT 309 00:12:51,170 --> 00:12:53,205 AFTERWARDS WHERE THEY DID A 310 00:12:53,272 --> 00:12:55,908 REANALYSIS OF THE DATA AND 311 00:12:55,975 --> 00:12:57,510 LOOKING FOR IMMORTAL TIME THEY 312 00:12:57,576 --> 00:12:58,677 FOUND THERE WAS NO DIFFERENCE 313 00:12:58,744 --> 00:13:00,713 BETWEEN THE GROUP THAT WON 314 00:13:00,779 --> 00:13:02,548 OSCARS AND THE OTHER THAT 315 00:13:02,615 --> 00:13:02,915 DIDN'T. 316 00:13:02,982 --> 00:13:04,750 AND WHILE THIS EXAMPLE IS A 317 00:13:04,817 --> 00:13:06,952 LITTLE SILLY, IT SHOWS IT CAN 318 00:13:07,019 --> 00:13:09,155 HAVE IMPACT ON CLINICAL 319 00:13:09,221 --> 00:13:09,655 DECISION-MAKING. 320 00:13:09,722 --> 00:13:11,123 HERE IS AN EXAMPLE IN 2019 321 00:13:11,190 --> 00:13:14,326 THAT CAME OUT IN INTERNAL 322 00:13:14,393 --> 00:13:14,860 MEDICINE. 323 00:13:14,927 --> 00:13:17,296 A STUDY CAME OUT WHERE THEY 324 00:13:17,363 --> 00:13:17,997 WERE GIVING PATIENTS 325 00:13:18,063 --> 00:13:19,131 ANTIBIOTICS DURING THE FIRST 326 00:13:19,198 --> 00:13:20,866 TWO YEARS OF THEIR ADMISSION 327 00:13:20,933 --> 00:13:27,273 WHEN THEY WERE ADMITTED WITH 328 00:13:27,339 --> 00:13:31,143 ASTHMA, THAT IT WAS A LONGER 329 00:13:31,210 --> 00:13:32,945 SUSTAINED POTENTIAL OUTCOME 330 00:13:33,012 --> 00:13:34,680 HOWEVER THE OTHER MONITOR ON 331 00:13:34,747 --> 00:13:38,083 THE LEFT CAME OUT AND SAID THE 332 00:13:38,150 --> 00:13:39,084 IMMORTAL TIME ANALYSIS IS 333 00:13:39,151 --> 00:13:41,120 NEEDED AND WHEN THE AUTHOR 334 00:13:41,187 --> 00:13:43,656 WENT BACK AND REANALYZED THEIR 335 00:13:43,722 --> 00:13:45,858 DATA, THEY ENDED UP TRASHING 336 00:13:45,925 --> 00:13:48,194 THE ENTIRE ARTICLE BECAUSE 337 00:13:48,260 --> 00:13:49,061 THEIR FINDINGS FULLY CHANGED 338 00:13:49,128 --> 00:13:52,364 AND AS A MATTER OF FACT, WENT 339 00:13:52,431 --> 00:13:54,767 FROM THE POINT WHERE THE 340 00:13:54,833 --> 00:13:57,136 ANTIBIOTICS FROM ASSOCIATED TO 341 00:13:57,203 --> 00:13:59,438 A 2-DAY LONGER LENGTH OF STAY 342 00:13:59,505 --> 00:14:00,472 TO ACTUALLY BEING NO 343 00:14:00,539 --> 00:14:01,974 DIFFERENCE IN LENGTH OF STAY. 344 00:14:02,041 --> 00:14:04,143 IN THE CANCER WORLD, THIS HAS 345 00:14:04,210 --> 00:14:04,710 ALSO HAPPENED. 346 00:14:04,777 --> 00:14:10,883 THERE WERE SEVERAL 347 00:14:10,950 --> 00:14:11,750 OBSERVATIONAL STUDIES ON 348 00:14:11,817 --> 00:14:12,985 SURVIVAL OF BREAST CANCER 349 00:14:13,052 --> 00:14:14,253 PATIENTS TO THE POINT WHERE IT 350 00:14:14,320 --> 00:14:16,121 WAS GOING TO POTENTIALLY 351 00:14:16,188 --> 00:14:17,289 IMPACT THE CLINICAL 352 00:14:17,356 --> 00:14:19,425 RECOMMENDATIONS THAT THESE 353 00:14:19,491 --> 00:14:20,492 STUDIES ARE CONSISTENTLY 354 00:14:20,559 --> 00:14:21,193 FINDING. 355 00:14:21,260 --> 00:14:25,297 SO THEY ENDED UP RUNNING 356 00:14:25,364 --> 00:14:28,300 SEVERAL RANDOMIZED CONTROL 357 00:14:28,367 --> 00:14:30,803 TRIALS, CLINICAL TRIALS AND 358 00:14:30,869 --> 00:14:32,438 FOUND THAT UNDERGOING SURGERY 359 00:14:32,504 --> 00:14:34,573 HAD NO IMPACT ON THE SURVIVAL 360 00:14:34,640 --> 00:14:37,710 OF THE PATIENT AND RESULTED IN 361 00:14:37,776 --> 00:14:38,577 NOT RECOMMENDING SURGERY BUT 362 00:14:38,644 --> 00:14:42,581 THERE WAS A POTENTIAL THAT 363 00:14:42,648 --> 00:14:48,520 WOMEN WERE UNDERGOING 364 00:14:48,587 --> 00:14:49,455 UNNECESSARY MASTECTOMIES FOR 365 00:14:49,521 --> 00:14:49,755 YEARS. 366 00:14:49,822 --> 00:14:52,091 AND TO MOVE AWAY FROM THESE 367 00:14:52,157 --> 00:14:53,726 EXAMPLES, A WORKING GROUP I 368 00:14:53,792 --> 00:14:56,462 WAS A PART OF SIMULATED DATA 369 00:14:56,528 --> 00:14:58,464 WHERE WE FORCED THE DATA TO 370 00:14:58,530 --> 00:15:00,232 SAY THERE WAS NO EFFECTIVE 371 00:15:00,299 --> 00:15:02,268 TREATMENT ON THE OUTCOME USING 372 00:15:02,334 --> 00:15:03,469 THAT BREAST CANCER EXAMPLE. 373 00:15:03,535 --> 00:15:06,605 SO IN OUR DATASET, WE DESIGNED 374 00:15:06,672 --> 00:15:09,541 IT SO THERE WAS NO EFFECT WITH 375 00:15:09,608 --> 00:15:09,908 SURGERY. 376 00:15:09,975 --> 00:15:12,278 AND WE FOUND WHEN WE ANALYZED 377 00:15:12,344 --> 00:15:14,780 OUR DATA AND ACCOUNTED FOR 378 00:15:14,847 --> 00:15:19,118 MORTAL TIME, THE ACTUAL HAZARD 379 00:15:19,184 --> 00:15:22,454 RATIO WAS .4 AND IN ALL OF THE 380 00:15:22,521 --> 00:15:25,057 ANALYSIS, WE GOT NONE OF THEM 381 00:15:25,124 --> 00:15:25,991 CROSSING NULL WHICH WAS THE 382 00:15:26,058 --> 00:15:28,193 TRUTH IN THE DATA SO THE BIAS 383 00:15:28,260 --> 00:15:30,663 INTRODUCED BY THE BIAS ALONE 384 00:15:30,729 --> 00:15:31,897 IS QUITE SUBSTANTIAL. 385 00:15:31,964 --> 00:15:36,335 SO IN SHORT, THE MORTAL TIME, 386 00:15:36,402 --> 00:15:38,771 DOES IT IMPACT CANCER, THE 387 00:15:38,837 --> 00:15:40,139 OVERWHELMING ANSWER IS YES. 388 00:15:40,205 --> 00:15:42,508 SO NOW WE USE OBSERVATIONAL 389 00:15:42,574 --> 00:15:45,577 DATA FOR A LOT OF OUR STUDIES. 390 00:15:45,644 --> 00:15:48,213 IT IS IMPORTANT WE USE REAL 391 00:15:48,280 --> 00:15:50,749 WORLD DATA BUT WE KNOW THERE 392 00:15:50,816 --> 00:15:54,053 IS A IMMORTAL TIME PROBLEM SO 393 00:15:54,119 --> 00:15:57,256 WE LOOK AT THE BIAS THE SAME 394 00:15:57,323 --> 00:16:03,329 WAY WE ANALYZE STUDIES ABOUT 395 00:16:03,395 --> 00:16:05,297 CONFOUNDING DATA BIAS, HOW CAN 396 00:16:05,364 --> 00:16:10,269 WE ADDRESS THIS IN A WAY THAT 397 00:16:10,336 --> 00:16:14,907 DOESN'T REFLECT AFFORD 398 00:16:14,973 --> 00:16:18,644 ABILITY IN OUR STUDIES. 399 00:16:18,711 --> 00:16:20,412 SO TARGET TRIAL EMULATION IS 400 00:16:20,479 --> 00:16:23,115 REALLY A WAY TO DESIGN 401 00:16:23,182 --> 00:16:27,019 OBSERVATIONAL STUDIES AND THIS 402 00:16:27,086 --> 00:16:28,620 IS PUBLISHED IN 2016 BUT I 403 00:16:28,687 --> 00:16:32,758 REMEMBER DURING MY TRAINING, 404 00:16:32,825 --> 00:16:37,262 YOU KNOW, DURING OBSERVATIONAL 405 00:16:37,329 --> 00:16:39,698 TRIAL, OBSERVATIONAL STUDY IN 406 00:16:39,765 --> 00:16:41,066 A OBSERVATIONAL TRIAL AND THIS 407 00:16:41,133 --> 00:16:43,469 APPROACH IS JUST A WAY TO FARM 408 00:16:43,535 --> 00:16:45,738 MALLIZE HOW WE DESCRIBE IT AND 409 00:16:45,804 --> 00:16:47,840 TO INCLUDE THIS INFORMATION IN 410 00:16:47,906 --> 00:16:48,307 OUR PUBLICATION. 411 00:16:48,374 --> 00:16:49,375 SO ESSENTIALLY WHAT YOU DO IS 412 00:16:49,441 --> 00:16:51,510 YOU GO THROUGH ALL OF THE 413 00:16:51,577 --> 00:16:53,145 PROTOCOL COMPONENTS OF THE 414 00:16:53,212 --> 00:16:55,314 TARGET TRIAL AND THEN YOU 415 00:16:55,381 --> 00:16:56,815 EMULATE EACH OF THOSE 416 00:16:56,882 --> 00:17:00,586 COMPONENTS IN YOUR 417 00:17:00,652 --> 00:17:01,353 OBSERVATIONAL DATA. 418 00:17:01,420 --> 00:17:03,455 SO HERE IS AN EXAMPLE AND 419 00:17:03,522 --> 00:17:05,591 AGAIN, I KNOW THIS IS PROBABLY 420 00:17:05,657 --> 00:17:07,393 SMALL AND I WILL ZOOM IN IN A 421 00:17:07,459 --> 00:17:13,799 SECOND BUT THIS IS AN EXAMPLE 422 00:17:13,866 --> 00:17:20,773 LOOKING AT SURGICAL INFECTION 423 00:17:20,839 --> 00:17:21,807 WITH PATIENTS WITH SECOND 424 00:17:21,874 --> 00:17:23,642 STAGE EARLY LUNG CANCER, 425 00:17:23,709 --> 00:17:26,812 TARGETED IN THIS POTENTIAL 426 00:17:26,879 --> 00:17:31,250 TRIAL, A TARGET TRIAL IN RAN 427 00:17:31,316 --> 00:17:36,221 ATTEMPT TO CONDUCT THE STUDY 428 00:17:36,288 --> 00:17:46,865 INCLUDED AND WHILE ADULTS ARE 429 00:18:06,985 --> 00:18:07,853 IN THE STUDY. 430 00:18:07,920 --> 00:18:10,255 TO WE LOOK AT TWO MONTHS AND 431 00:18:10,322 --> 00:18:11,890 SIX MONTHS AND EVEN THOUGH WE 432 00:18:11,957 --> 00:18:15,294 CAN SEE OH THAT IS GOING TO 433 00:18:15,360 --> 00:18:16,562 INTRODUCE IMMORTAL TIME 434 00:18:16,628 --> 00:18:18,263 BECAUSE WHAT THE STRATEGIES 435 00:18:18,330 --> 00:18:20,299 HAVE OVER TIME AND THEN HERE 436 00:18:20,365 --> 00:18:25,804 WE CAN SEE IN A TREATMENT, IN 437 00:18:25,871 --> 00:18:28,941 THE TRIAL THEY ARE RANDOMLY 438 00:18:29,007 --> 00:18:32,578 ASSIGNED AND THEN THE 439 00:18:32,644 --> 00:18:33,378 TREATMENT STRATEGY, 440 00:18:33,445 --> 00:18:34,112 RANDOMIZATIONS FOR CLONING 441 00:18:34,179 --> 00:18:37,449 WHICH IS THE CLONING PROCESS. 442 00:18:37,516 --> 00:18:40,652 SO THIS IS A WAY TO REALLY 443 00:18:40,719 --> 00:18:42,187 EXPLICITLY DESCRIBE AND COME 444 00:18:42,254 --> 00:18:43,322 UP WITH SOLUTIONS IN ORDER TO 445 00:18:43,388 --> 00:18:48,627 MAKE SURE THAT YOU HAVE A WELL 446 00:18:48,694 --> 00:18:50,829 DESIGNED OBSERVATIONAL STUDY. 447 00:18:50,896 --> 00:18:53,131 SO THERE ARE DIFFERENT METHODS 448 00:18:53,198 --> 00:18:55,834 TO ADDRESS THESE TIME-RELATED 449 00:18:55,901 --> 00:18:58,937 BIASES SO IT IS A WAY TO 450 00:18:59,004 --> 00:18:59,872 INTRODUCE RANDOMIZATION OF 451 00:18:59,938 --> 00:19:01,573 TREATMENT INTO OUR 452 00:19:01,640 --> 00:19:02,307 OBSERVATIONAL DATA AND THE WAY 453 00:19:02,374 --> 00:19:04,510 WE ARE ABLE TO DO THAT IS 454 00:19:04,576 --> 00:19:06,578 BECAUSE YOU KNOW IN BOTH A 455 00:19:06,645 --> 00:19:08,714 CLINICAL TRIAL AND 456 00:19:08,780 --> 00:19:10,415 OBSERVATIONAL STUDY, WHEN WE 457 00:19:10,482 --> 00:19:11,483 INITIALLY ENROLL THOSE 458 00:19:11,550 --> 00:19:12,985 PATIENTS, WE DON'T KNOW WHAT 459 00:19:13,051 --> 00:19:14,453 TREATMENT THEY ARE GOING TO 460 00:19:14,520 --> 00:19:15,854 RECEIVE OR ANY TREATMENT, FOR 461 00:19:15,921 --> 00:19:16,555 THAT MATTER. 462 00:19:16,622 --> 00:19:21,393 IT IS UNKNOWN AT THE START OF 463 00:19:21,460 --> 00:19:22,060 FOLLOW UP. 464 00:19:22,127 --> 00:19:23,762 EVEN IF WE HAVE DATA 465 00:19:23,829 --> 00:19:24,930 COLLECTION ALREADY, TWO YEARS 466 00:19:24,997 --> 00:19:27,633 OF FOLLOW UP DATA ON THEM, ON 467 00:19:27,699 --> 00:19:28,767 THAT DATA ENROLLMENT, WE DON'T 468 00:19:28,834 --> 00:19:29,768 KNOW WHAT THEY ARE GOING TO 469 00:19:29,835 --> 00:19:33,171 SEE AND THAT IS THE SAME FOR 470 00:19:33,238 --> 00:19:34,773 CLINICAL TRIALS BEFORE 471 00:19:34,840 --> 00:19:35,707 RANDOMIZATION. 472 00:19:35,774 --> 00:19:38,243 SO WE USE THIS PATH TO BUILD A 473 00:19:38,310 --> 00:19:40,312 CLINICAL TRIAL IN OUR DATA SO 474 00:19:40,379 --> 00:19:48,854 WE WILL WALK THROUGH WITH TREE 475 00:19:48,921 --> 00:19:52,057 STEPS AND THIS PAPER UNDER 476 00:19:52,124 --> 00:19:54,226 REVIEW, TRYING TO DEVELOPMENT 477 00:19:54,293 --> 00:19:54,960 VISUALIZATION THROUGHOUT AND 478 00:19:55,027 --> 00:19:58,997 HOPEFULLY THIS WILL BE HELPFUL 479 00:19:59,064 --> 00:20:04,536 AND MAKE THIS MESSAGE 480 00:20:04,603 --> 00:20:10,876 UNDERSTAND A LITTLE COMPLEX IN 481 00:20:10,943 --> 00:20:12,611 A WAY THAT IS APPROACHABLE. 482 00:20:12,678 --> 00:20:14,913 SO FOR OUR EXAMPLE HERE, 483 00:20:14,980 --> 00:20:16,715 UNDERGOING SURGERY SIX MONTHS, 484 00:20:16,782 --> 00:20:18,317 182 DAYS TO TIE INTO THE 485 00:20:18,383 --> 00:20:19,651 FIGURE HERE. 486 00:20:19,718 --> 00:20:21,119 AFTER DIAGNOSIS OF EARLY STAGE 487 00:20:21,186 --> 00:20:23,422 LUNG CANCER AND ONE-YEAR 488 00:20:23,488 --> 00:20:23,789 MORTALITY. 489 00:20:23,855 --> 00:20:27,326 SO ON THE LEFT SIDE HERE, WE 490 00:20:27,392 --> 00:20:28,460 JUST HAVE FIVE PATIENTS IN 491 00:20:28,527 --> 00:20:28,994 FOLLOW UP TIME. 492 00:20:29,061 --> 00:20:31,496 WE CAN SEE THE FIRST TWO 493 00:20:31,563 --> 00:20:32,364 PATIENTS ULTIMATELY UNDERGO 494 00:20:32,431 --> 00:20:37,336 SURGERY AND WE CAN SEE IN THE 495 00:20:37,402 --> 00:20:39,771 GREEN THE IMMORTAL TIME IS 496 00:20:39,838 --> 00:20:42,507 PHASED IN IF WE DO A STUDY 497 00:20:42,574 --> 00:20:44,543 WHERE WE FLAG THE THREE WHO 498 00:20:44,610 --> 00:20:47,546 WERE TREATED AND COMPARE THEM 499 00:20:47,613 --> 00:20:50,649 TO THOSE WHO HAD NO TREATMENT. 500 00:20:50,716 --> 00:20:52,517 SO THE TREATMENT DESIGN, YOU 501 00:20:52,584 --> 00:20:55,354 CAN SEE THE FIVE PATIENT WHO 502 00:20:55,420 --> 00:20:58,557 UNDERGO SURGERY, THE FIRST 503 00:20:58,624 --> 00:21:00,392 PATIENT DIES, PATIENT 3 DIES 504 00:21:00,459 --> 00:21:01,460 AFTER SURGERY, PATIENT 4 WE 505 00:21:01,526 --> 00:21:03,528 FOLLOW FOR A FULL YEAR AND 506 00:21:03,595 --> 00:21:05,564 THEY DON'T UNDERGO SURGERY AND 507 00:21:05,631 --> 00:21:06,765 THEN PATIENT 5 WE FOLLOW MOST 508 00:21:06,832 --> 00:21:08,667 OF THE YEAR BUT THEY DIED AT 509 00:21:08,734 --> 00:21:11,737 THE END. 510 00:21:11,803 --> 00:21:14,039 IF YOU ARE VISUALIZING WHAT 511 00:21:14,106 --> 00:21:16,441 THE DATA TABLE LOOKS LIKE, ON 512 00:21:16,508 --> 00:21:17,743 THE RIGHT SIDE YOU CAN SEE 513 00:21:17,809 --> 00:21:20,746 WHAT IT LOOKS LIKE, FIVE ROWS 514 00:21:20,812 --> 00:21:25,050 OF DATA, FIVE PARTICIPANTS, WE 515 00:21:25,117 --> 00:21:26,518 HAVE THE SURGERY DATE THEY 516 00:21:26,585 --> 00:21:28,820 UNDERWENT AND I WOULD LIKE TO 517 00:21:28,887 --> 00:21:30,355 NOTE THAT WE HAVE TO HAVE SOME 518 00:21:30,422 --> 00:21:32,290 KIND OF TIME FRAME OR DATE 519 00:21:32,357 --> 00:21:34,459 ATTACHED TO THE TREATMENT. 520 00:21:34,526 --> 00:21:36,662 IF YOU JUST PUT YES OR NO AND 521 00:21:36,728 --> 00:21:38,296 NOT WHEN THEY DID IT, YOU 522 00:21:38,363 --> 00:21:39,598 CAN'T REALLY USE THIS METHOD. 523 00:21:39,665 --> 00:21:41,900 AND THEN WE HAVE THE OUTCOMES 524 00:21:41,967 --> 00:21:44,202 WHETHER THEY DIED OR, YOU 525 00:21:44,269 --> 00:21:45,704 KNOW, WERE SENSITIVE HERE AND 526 00:21:45,771 --> 00:21:46,672 WHAT THE TOTAL FOLLOW UP TIME 527 00:21:46,738 --> 00:21:46,938 IS. 528 00:21:47,005 --> 00:21:56,081 SO THIS IS A PRETTY STANDARD 529 00:21:56,148 --> 00:21:58,116 HAZARD REDUCTION HERE, COST 530 00:21:58,183 --> 00:21:58,917 REDUCTION, ADDITIONAL 531 00:21:58,984 --> 00:21:59,885 INFORMATION OF POTENTIAL 532 00:21:59,951 --> 00:22:02,587 CONFOUNDERS BUT TO KEEP IT 533 00:22:02,654 --> 00:22:04,890 SIMPLE BECAUSE THESE ARE THE 534 00:22:04,956 --> 00:22:08,493 FIVE VARIABLES -- 535 00:22:08,560 --> 00:22:09,127 [INDISCERNIBLE] 536 00:22:09,194 --> 00:22:11,129 SO STEP 1 IS TO CLONE THE 537 00:22:11,196 --> 00:22:12,731 PARTICIPANT AND WHAT WE MEAN 538 00:22:12,798 --> 00:22:14,900 BY CLONE IS WE MAKE COPIES. 539 00:22:14,966 --> 00:22:17,436 SO YOU HAVE FIVE PARTICIPANTS 540 00:22:17,502 --> 00:22:21,673 BUT TEN ROWS OF DATA, DATA 541 00:22:21,740 --> 00:22:23,975 POINTS HERE AND WE RANDOMLY 542 00:22:24,042 --> 00:22:26,712 ASSIGN ONE OF THE CLONES OR 543 00:22:26,778 --> 00:22:28,747 COPIES TO UNDERGO TREATMENT A, 544 00:22:28,814 --> 00:22:30,015 SOME UNDERGO SURGERY AND THE 545 00:22:30,082 --> 00:22:31,616 OTHER IS ASSIGNED TO TREATMENT 546 00:22:31,683 --> 00:22:32,951 B AND NO SURGERY. 547 00:22:33,018 --> 00:22:35,921 IF YOU WANT TO STUDY THREE 548 00:22:35,987 --> 00:22:39,124 ARMS, SURGERY, NO SURGERY AND 549 00:22:39,191 --> 00:22:41,860 THEN CHEMO OR RADIATION AND WE 550 00:22:41,927 --> 00:22:44,196 WOULD MAKE THREE COPIES BUT WE 551 00:22:44,262 --> 00:22:45,597 HAVEN'T TOUCHED THE DATA AT 552 00:22:45,664 --> 00:22:47,666 ALL, WE JUST ADDED PEOPLE TO 553 00:22:47,733 --> 00:22:52,671 THE DATASET AND ADDED WHERE WE 554 00:22:52,738 --> 00:22:54,406 SAY TREATMENT STRATEGY 1 555 00:22:54,473 --> 00:22:55,640 WORKED HERE. 556 00:22:55,707 --> 00:22:57,709 SO THEN THE NEXT STEP IS TO 557 00:22:57,776 --> 00:22:59,311 FOLLOW THE CLONES AND COPIES 558 00:22:59,377 --> 00:23:00,178 AND SENSOR THEM. 559 00:23:00,245 --> 00:23:02,547 SO WHAT DOES THIS MEAN? 560 00:23:02,614 --> 00:23:04,316 FOR PARTICIPANT 1 IN THE LIGHT 561 00:23:04,382 --> 00:23:06,518 BLUE IS THE GROUP THAT 562 00:23:06,585 --> 00:23:07,452 UNDERWENT SURGERY SO THE 563 00:23:07,519 --> 00:23:10,188 QUESTION IS DID THEY UNDERGO 564 00:23:10,255 --> 00:23:14,159 SURGERY IN SIX MONTHS AND YOU 565 00:23:14,226 --> 00:23:20,031 CAN SEE YES, WE CONTINUE TO 566 00:23:20,098 --> 00:23:21,800 FOLLOW THEM AND WE ARE 567 00:23:21,867 --> 00:23:23,835 RECEIVING TREATMENT AND 568 00:23:23,902 --> 00:23:26,104 ASSIGNED TO A GROUP. 569 00:23:26,171 --> 00:23:28,874 SO THE SECOND GROUP WE 570 00:23:28,940 --> 00:23:30,809 DEFINED, THAT PERSON UNDERGOES 571 00:23:30,876 --> 00:23:34,212 SURGERY AT SAY THREE MONTHS 572 00:23:34,279 --> 00:23:36,381 AND SO THERE IS NO INFORMATION 573 00:23:36,448 --> 00:23:39,017 ON THE TREATMENT ARM SO WE 574 00:23:39,084 --> 00:23:41,253 STOPPED FOLLOWING THEM. 575 00:23:41,319 --> 00:23:44,055 FOR PARTICIPANT 2 THEY DON'T 576 00:23:44,122 --> 00:23:47,092 UNDERGO SURGERY SO AT THE SIX 577 00:23:47,159 --> 00:23:49,194 MONTH MARK, WE SENSOR THEM 578 00:23:49,261 --> 00:23:53,031 BECAUSE THE SURGERY IS FLEDDED 579 00:23:53,098 --> 00:23:54,766 FLED-- NEEDED FOR THE 580 00:23:54,833 --> 00:23:55,233 PROTOCOL. 581 00:23:55,300 --> 00:23:57,068 AND THEN THE SECOND GROUP, 582 00:23:57,135 --> 00:24:00,872 THEY DON'T UNDERGO SURGERY, WE 583 00:24:00,939 --> 00:24:02,240 KEEP FOLLOWING THEM AND KEEP 584 00:24:02,307 --> 00:24:04,242 DOING THAT FOR PERSON 3, 4 AND 585 00:24:04,309 --> 00:24:09,080 5 AND LOOK TO SEE WHEN THEY 586 00:24:09,147 --> 00:24:10,715 WERE ASSIGNED, DID THEY 587 00:24:10,782 --> 00:24:12,551 UNDERGO SURGERY AT SIX MONTHS, 588 00:24:12,617 --> 00:24:15,887 IF THEY DO UNDERGO SURGERY IN 589 00:24:15,954 --> 00:24:17,956 THE NONTREATMENT TIME, THEY 590 00:24:18,023 --> 00:24:18,957 GUESS SENSORED AFTER THE 591 00:24:19,024 --> 00:24:19,624 SURGERY. 592 00:24:19,691 --> 00:24:22,227 IF THERE IS A PERSON WHO 593 00:24:22,294 --> 00:24:23,562 UNDERWENT SURGERY AFTER SIX 594 00:24:23,628 --> 00:24:24,429 MONTHS BECAUSE THAT IS NOT 595 00:24:24,496 --> 00:24:27,532 PART OF THE DEFINITION, THEY 596 00:24:27,599 --> 00:24:28,366 FALL INTO THE NONTREATMENT 597 00:24:28,433 --> 00:24:29,367 ARM. 598 00:24:29,434 --> 00:24:34,139 AND THEN THE LAST STEP IS TO 599 00:24:34,206 --> 00:24:37,809 REWEIGHT THE CLONE AND SO 600 00:24:37,876 --> 00:24:40,512 BASICALLY YOU JUST REORGANIZE 601 00:24:40,579 --> 00:24:47,619 THE DATA HERE SO THAT THE FIVE 602 00:24:47,686 --> 00:24:50,021 PATIENTS IN TREATMENT A ARE 603 00:24:50,088 --> 00:24:52,057 TOGETHER, FIVE PATIENTS FROM 604 00:24:52,123 --> 00:24:54,559 TREATMENT B ARE TOGETHER AND 605 00:24:54,626 --> 00:24:58,430 THEN WE SAY OKAY THERE'S THREE 606 00:24:58,496 --> 00:25:00,899 PEOPLE SENSORED AT TIME .4 SO 607 00:25:00,966 --> 00:25:04,269 PERSON NUMBER 1 GETS UPGRADED 608 00:25:04,336 --> 00:25:05,337 TO REPRESENT THOSE INDIVIDUALS 609 00:25:05,403 --> 00:25:07,572 WHICH IS HOW SENSOR WEIGHTING 610 00:25:07,639 --> 00:25:08,773 IS NORMALLY PERFORMED. 611 00:25:08,840 --> 00:25:11,009 YOU CAN SEE THE REGRESSION, 612 00:25:11,076 --> 00:25:13,678 THIS ISN'T ANYTHING NEW. 613 00:25:13,745 --> 00:25:15,480 SENSOR WEIGHTING HAS BEEN 614 00:25:15,547 --> 00:25:17,549 AROUND FOR QUITE A WHILE, 615 00:25:17,616 --> 00:25:19,451 WE'RE JUST APPLYING IT HERE SO 616 00:25:19,517 --> 00:25:23,088 FOR THE SURGERY ARM, USING 617 00:25:23,154 --> 00:25:25,523 CHEMO AND SURGERY ALL OF IT AT 618 00:25:25,590 --> 00:25:27,559 THE SIX MONTH MARK, THAT IS 619 00:25:27,626 --> 00:25:29,628 WHERE EVERYONE IS GOING TO 620 00:25:29,694 --> 00:25:31,529 UNDERGO SURGERY BECAUSE IT HAS 621 00:25:31,596 --> 00:25:34,065 NOT BEEN DESIGNED YET AND THEN 622 00:25:34,132 --> 00:25:35,467 IN THE CHEMO, WE HAD ONE 623 00:25:35,533 --> 00:25:37,669 PERSON WHO HAD SURGERY AND 624 00:25:37,736 --> 00:25:41,673 THEY GET SENSORED AND EVERYONE 625 00:25:41,740 --> 00:25:42,207 ELSE IS UP-WEIGHTED. 626 00:25:42,274 --> 00:25:44,509 SO THIS IS THE SAME PICTURE 627 00:25:44,576 --> 00:25:47,846 AND YOU CAN SEE THE DATASET 628 00:25:47,913 --> 00:25:53,084 HAS A TREATMENT ARM, SEVERAL 629 00:25:53,151 --> 00:25:54,920 ZEROS ASSIGNED WHEN WE 630 00:25:54,986 --> 00:25:56,655 ASSIGNED THE DATA AND THE ONLY 631 00:25:56,721 --> 00:26:00,091 THING WORTH NOTING HERE IS THE 632 00:26:00,158 --> 00:26:01,459 DATA, BECAUSE YOU DON'T WEIGHT 633 00:26:01,526 --> 00:26:03,194 THE DATA BEFORE THE SENSOR 634 00:26:03,261 --> 00:26:08,099 MARK, YOU CAN SEE WE HAVE 635 00:26:08,166 --> 00:26:10,201 OBSERVATIONS HERE ON 182, THE 636 00:26:10,268 --> 00:26:12,537 OUTCOME OF 1 AND THEN THE 637 00:26:12,604 --> 00:26:16,274 SECOND OBSERVATION STARTS AT 638 00:26:16,341 --> 00:26:18,176 183 AND THEN AT 13 WHEN THEY 639 00:26:18,243 --> 00:26:21,546 DIE AND HAVE THE OUTCOME. 640 00:26:21,613 --> 00:26:24,849 AND THIS IS PRETTY STANDARD I 641 00:26:24,916 --> 00:26:26,718 WOULD SAY CLONE SENSOR 642 00:26:26,785 --> 00:26:27,252 WEIGHTING STRATEGY. 643 00:26:27,319 --> 00:26:29,354 THIS IS WHAT THE DATE LOOKS 644 00:26:29,421 --> 00:26:31,356 LIKE WHEN YOU USE SENSOR 645 00:26:31,423 --> 00:26:32,390 WEIGHTING. 646 00:26:32,457 --> 00:26:34,559 THE STRATEGIES OF SENSOR 647 00:26:34,626 --> 00:26:36,828 WAITING HAVE NOT BEEN ADAPTED 648 00:26:36,895 --> 00:26:38,797 HERE AT ALL AND SO YOU SHOULD 649 00:26:38,863 --> 00:26:41,333 BE ABLE TO HANDLE THIS, NO 650 00:26:41,399 --> 00:26:41,666 PROBLEM. 651 00:26:41,733 --> 00:26:43,368 SO HERE ARE THE THREE STEPS, 652 00:26:43,435 --> 00:26:47,872 THAT IS ALL THERE IS TO CLONE 653 00:26:47,939 --> 00:26:49,941 CENSOR WEIGHTING AND AT THE 654 00:26:50,008 --> 00:26:53,211 OUTCOME, YOU CAN PERFORM ANY 655 00:26:53,278 --> 00:26:59,951 ANALYSIS YOU WANT. 656 00:27:00,018 --> 00:27:02,020 YOU CAN USE TREATMENT, 657 00:27:02,087 --> 00:27:03,154 ASSIGNED TREATMENT AND THESE 658 00:27:03,221 --> 00:27:04,556 LAST TWO STEPS ARE ACTUALLY 659 00:27:04,622 --> 00:27:06,424 THE SAME STEPS YOU FACE WHEN 660 00:27:06,491 --> 00:27:07,492 ESTIMATING THE PROTOCOL EFFECT 661 00:27:07,559 --> 00:27:08,793 IN A CLINICAL TRIAL. 662 00:27:08,860 --> 00:27:11,496 SO IF YOU HAVE EVER GONE FROM 663 00:27:11,563 --> 00:27:13,999 THE INTENTION TO TREAT TO THE 664 00:27:14,065 --> 00:27:15,834 PREFERRED PROTOCOL EFFECT, OR 665 00:27:15,900 --> 00:27:18,503 THE ACTUAL TREATMENT EFFECT IN 666 00:27:18,570 --> 00:27:19,637 A CLINICAL TRIAL, THESE ARE 667 00:27:19,704 --> 00:27:20,805 THE SAME THINGS YOU WOULD HAVE 668 00:27:20,872 --> 00:27:23,942 TO DO WITH THE DATA IN ORDER 669 00:27:24,009 --> 00:27:25,043 TO ESTIMATE THAT. 670 00:27:25,110 --> 00:27:27,012 SO THIS REALLY ISN'T 671 00:27:27,078 --> 00:27:28,380 DEVELOPING ANYTHING NEW, IT IS 672 00:27:28,446 --> 00:27:30,115 TAKING THINGS WE ALREADY DO 673 00:27:30,181 --> 00:27:32,851 AND APPLYING THEM TO THIS 674 00:27:32,917 --> 00:27:34,419 TARGET TRIAL AND FRAMEWORK. 675 00:27:34,486 --> 00:27:37,756 THE OTHER THING WE CAN DO WITH 676 00:27:37,822 --> 00:27:39,958 CLONE SENSOR WEIGHTING IS 677 00:27:40,025 --> 00:27:42,494 CREATE FLUID DIAGRAMS TO 678 00:27:42,560 --> 00:27:43,328 INCLUSION, EXCLUSION, 679 00:27:43,395 --> 00:27:44,129 BASICALLY THE SAME YOU WOULD 680 00:27:44,195 --> 00:27:46,197 IN A CLINICAL TRIAL. 681 00:27:46,264 --> 00:27:47,699 THE ONLY DIFFERENCE IS IN THE 682 00:27:47,766 --> 00:27:49,901 MIDDLE HERE YOU SEE THERE IS A 683 00:27:49,968 --> 00:27:52,337 CLONING STEP AND THEN YOUR 684 00:27:52,404 --> 00:27:53,138 DATASET DOUBLES. 685 00:27:53,204 --> 00:27:56,775 SO IN THIS EXAMPLE WE GO FROM 686 00:27:56,841 --> 00:28:02,847 2300 TO 2600 PARTICIPANTS OR 687 00:28:02,914 --> 00:28:03,748 2800 PARTICIPANTS, MY 688 00:28:03,815 --> 00:28:05,717 APOLOGIES AND HALF OF THEM GET 689 00:28:05,784 --> 00:28:08,153 ASSIGNED TO TREATMENT A, HALF 690 00:28:08,219 --> 00:28:09,454 GET ASSIGNED TO TREATMENT B, 691 00:28:09,521 --> 00:28:11,689 YOU CAN SEE WHAT THEIR FOLLOW 692 00:28:11,756 --> 00:28:14,459 UP IS AND HOW MANY ARE 693 00:28:14,526 --> 00:28:15,060 NONADHERENT. 694 00:28:15,126 --> 00:28:18,229 AND WHEN YOU USE THESE 695 00:28:18,296 --> 00:28:20,298 APPROACHES, YOU NOT ONLY 696 00:28:20,365 --> 00:28:20,999 INCLUDE POTENTIALLY THOSE 697 00:28:21,066 --> 00:28:24,769 FIGURES THAT YOU SAW ON THE 698 00:28:24,836 --> 00:28:28,106 LAST SLIDE TO VISUALIZE HOW WE 699 00:28:28,173 --> 00:28:30,175 SET THE DATA BUT ALSO FOR THIS 700 00:28:30,241 --> 00:28:32,143 TABLE WHERE YOU OUTLINE THE 701 00:28:32,210 --> 00:28:40,418 TARGET TRIAL AND OBSERVATIONAL 702 00:28:40,485 --> 00:28:40,718 DATA. 703 00:28:40,785 --> 00:28:44,055 NOW, YOU MAY BE THINKING 704 00:28:44,122 --> 00:28:46,357 AREN'T THERE EASIER WAYS TO 705 00:28:46,424 --> 00:28:47,192 ALLOW FOR IMMORTAL TIME AND 706 00:28:47,258 --> 00:28:50,195 THE ANSWER IS YES AND NO AND I 707 00:28:50,261 --> 00:28:51,162 WILL EXPLAIN WHY. 708 00:28:51,229 --> 00:28:52,730 SO GOING BACK TO THE 709 00:28:52,797 --> 00:28:53,998 ACCUMULATION STUDY FROM THE 710 00:28:54,065 --> 00:28:58,970 RESEARCH TEAM WE PERFORMED, WE 711 00:28:59,037 --> 00:29:03,508 DID FIND TWO CLONE SENSOR 712 00:29:03,575 --> 00:29:04,609 WEIGHTING CASES. 713 00:29:04,676 --> 00:29:07,245 ONE WAS USED A TIME BARRIER 714 00:29:07,312 --> 00:29:09,147 EXPOSURE AND THE OTHER CALLED 715 00:29:09,214 --> 00:29:10,014 A LANDMARK APPROACH. 716 00:29:10,081 --> 00:29:13,451 SO TO GET INTO IT AND THIS IS 717 00:29:13,518 --> 00:29:18,456 A NICE TABLE WE INCLUDED TO 718 00:29:18,523 --> 00:29:20,792 THE ASSIGNED PATIENTS INCLUDED 719 00:29:20,859 --> 00:29:22,160 AND INTERPRETATION BUT WHEN 720 00:29:22,227 --> 00:29:24,362 YOU DO A TIME VARYING 721 00:29:24,429 --> 00:29:26,664 EXPOSURE, YOU FOLLOW A PERSON, 722 00:29:26,731 --> 00:29:28,399 CONSIDER THEM UNEXPOSED TILL 723 00:29:28,466 --> 00:29:30,435 THEY UNDERGO TREATMENT OR 724 00:29:30,502 --> 00:29:33,071 SURGERY AND THEN TOGGLE THEM. 725 00:29:33,138 --> 00:29:37,542 SO YOU END UP WITH TWO ROWS OF 726 00:29:37,609 --> 00:29:42,046 DATA PER PARTICIPATE AND SOME 727 00:29:42,113 --> 00:29:44,015 DATA IS INCLUDED IN THE 728 00:29:44,082 --> 00:29:45,750 NONINCLUDED ARM AND SOME OF IT 729 00:29:45,817 --> 00:29:48,620 ENDS UP IN THE INCLUDED ARM. 730 00:29:48,686 --> 00:29:53,958 SO THEN YOU HAVE PATIENTS WHO 731 00:29:54,025 --> 00:29:58,029 UNDERWENT SURGERY TO PATIENTS 732 00:29:58,096 --> 00:30:01,199 WHO NEVER UNDERWENT SURGERY. 733 00:30:01,266 --> 00:30:04,169 A DIFFERENCE OF SIX MONTHS IS 734 00:30:04,235 --> 00:30:07,038 FINE BUT THE QUESTION HERE IS 735 00:30:07,105 --> 00:30:09,574 ONE TO TWO YEARS THE SAME? 736 00:30:09,641 --> 00:30:11,943 TYPICALLY THE ANSWER IS NO BUT 737 00:30:12,010 --> 00:30:17,148 SOMETIMES THAT IS NOT TRUE AND 738 00:30:17,215 --> 00:30:18,483 CLONE-CENSOR-WEIGHTING IS 739 00:30:18,550 --> 00:30:20,785 SOMETHING WE CAN USE BUT A THE 740 00:30:20,852 --> 00:30:23,988 VARIATION THAT WILL OCCUR IN 741 00:30:24,055 --> 00:30:25,223 THE NITTY-GRITTY, NOT EVERY 742 00:30:25,290 --> 00:30:27,525 PATIENT IS GOING TO UNDERGO 743 00:30:27,592 --> 00:30:31,896 SURGERY BY THE SAME SURGEON, 744 00:30:31,963 --> 00:30:38,770 THEIR SURGERY TIMES WILL VARY, 745 00:30:38,836 --> 00:30:43,841 THAT WILL VARY FROM PATIENT TO 746 00:30:43,908 --> 00:30:46,611 PATIENT BUT SOME PEOPLE MIGHT 747 00:30:46,678 --> 00:30:48,813 UNDERGO SURGERY AT SIX MONTHS, 748 00:30:48,880 --> 00:30:51,683 OTHERS AT TWO OR THREE MONTHS 749 00:30:51,749 --> 00:30:54,185 BUT THE TREATMENT VARIATION IS 750 00:30:54,252 --> 00:30:56,454 WHERE WE'RE SAYING IS IT 751 00:30:56,521 --> 00:30:58,523 RELEVANT AND DOES IT MATTER? 752 00:30:58,590 --> 00:31:01,159 ALL THE PEOPLE WHO UNDERGO 753 00:31:01,226 --> 00:31:02,727 SURGERY ARE ESSENTIALLY THE 754 00:31:02,794 --> 00:31:05,363 SAME AND THERE ARE NO 755 00:31:05,430 --> 00:31:06,564 DIFFERENCE THAT WILL 756 00:31:06,631 --> 00:31:07,432 FUNDAMENTALLY IMPACT THE 757 00:31:07,498 --> 00:31:09,200 TREATMENT ON THE OUTCOME. 758 00:31:09,267 --> 00:31:12,036 HOWEVER WHEN YOU ARE COMPARING 759 00:31:12,103 --> 00:31:14,105 SOMEONE WHO GOES UNDER SURGERY 760 00:31:14,172 --> 00:31:19,177 IN SIX MONTHS VERSUS TWO 761 00:31:19,244 --> 00:31:23,047 YEARS, THAT DIFFERENCE IS NO 762 00:31:23,114 --> 00:31:25,550 LONGER RELEVANT AND THAT IS A 763 00:31:25,617 --> 00:31:26,517 FUNDAMENTAL ASSUMPTION WE MAKE 764 00:31:26,584 --> 00:31:29,520 EVERY TIME WE DO A 765 00:31:29,587 --> 00:31:30,888 OBSERVATIONAL STUDY SO WHETHER 766 00:31:30,955 --> 00:31:35,126 YOU SPELL IT OUT, IT IS THERE. 767 00:31:35,193 --> 00:31:39,797 SO TIME VARYING EXPOSURE 768 00:31:39,864 --> 00:31:41,299 REALLY HIGHLIGHTS A CONCERN 769 00:31:41,366 --> 00:31:43,268 THAT WE ARE MAKING THIS 770 00:31:43,334 --> 00:31:44,535 ASSUMPTION WITH OUR DATA. 771 00:31:44,602 --> 00:31:46,170 AND THEN THE SECOND EXAMPLE IS 772 00:31:46,237 --> 00:31:47,305 TO THE LANDMARK APPROACH. 773 00:31:47,372 --> 00:31:52,510 AND WHAT A LANDMARK APPROACH 774 00:31:52,577 --> 00:31:55,380 DOES, IN THIS CASE THE 775 00:31:55,446 --> 00:31:56,347 SIXTH-MONTH POINT, WE REQUIRE 776 00:31:56,414 --> 00:31:57,949 EVERYONE TO BE ALIVE AND NOT 777 00:31:58,016 --> 00:31:58,683 DROP OUT. 778 00:31:58,750 --> 00:32:00,418 WE CHECK TO SEE WHAT 779 00:32:00,485 --> 00:32:01,786 EVERYONE'S TREATMENT IS DURING 780 00:32:01,853 --> 00:32:03,054 THAT PERIOD AND START FOLLOW 781 00:32:03,121 --> 00:32:06,924 UP AT THAT LANDMARK SO WE 782 00:32:06,991 --> 00:32:08,326 ACTUALLY START OUR SURVIVAL 783 00:32:08,393 --> 00:32:09,894 ANALYSES, START FOLLOW UP AT 784 00:32:09,961 --> 00:32:12,196 SIX MONTHS INSTEAD OF AT DATA 785 00:32:12,263 --> 00:32:12,563 DIAGNOSIS. 786 00:32:12,630 --> 00:32:15,199 AND WHAT THIS DOES IS IT 787 00:32:15,266 --> 00:32:17,135 ESTIMATES THE EFFECTS OF 788 00:32:17,201 --> 00:32:18,503 TREATMENT OF UNDERGOING 789 00:32:18,569 --> 00:32:20,371 SURGERY IN SIX MONTHS BUT OF 790 00:32:20,438 --> 00:32:22,340 ALL THOSE WHO SURVIVE DURING 791 00:32:22,407 --> 00:32:23,241 THE LANDMARK. 792 00:32:23,308 --> 00:32:24,642 SO WE'RE NOW DROPPING ANYONE 793 00:32:24,709 --> 00:32:26,644 WHO DIED WITHIN THE SIX MONTHS 794 00:32:26,711 --> 00:32:28,313 OR DROPPED OUT IN THE FIRST 795 00:32:28,379 --> 00:32:29,947 SIX MONTHS AND THEN WE HAVE TO 796 00:32:30,014 --> 00:32:31,616 ASK OURSELVES ARE THE 797 00:32:31,683 --> 00:32:33,017 INDIVIDUALS WHO SURVIVE AND 798 00:32:33,084 --> 00:32:36,688 STAYING IN THE STUDY FOR 799 00:32:36,754 --> 00:32:38,289 X-NUMBER OF MONTHS, THE SAME 800 00:32:38,356 --> 00:32:40,124 AS THOUGH WHO DO NOT? 801 00:32:40,191 --> 00:32:42,460 AND SIMILAR TO THE CLINICAL 802 00:32:42,527 --> 00:32:45,330 TRIAL WITH THE OBSERVATIONAL 803 00:32:45,396 --> 00:32:46,831 DATA ISSUE, WE HAVE TO ASK 804 00:32:46,898 --> 00:32:48,466 QUESTIONS WHETHER OUR DATA 805 00:32:48,533 --> 00:32:51,803 WILL BE GENERALIZABLE TO THE 806 00:32:51,869 --> 00:32:53,638 LARGER CANCER POPULATION AND 807 00:32:53,705 --> 00:32:59,110 THOSE WHO SURVIVE AT SIX 808 00:32:59,177 --> 00:33:00,978 MONTHS IS THAT REPRESENTATIVE 809 00:33:01,045 --> 00:33:01,979 AS A WHOLE? 810 00:33:02,046 --> 00:33:05,116 AND WITH BREAST CANCER, FOR 811 00:33:05,183 --> 00:33:06,250 EXAMPLE, SURVIVAL RATES ARE 812 00:33:06,317 --> 00:33:07,885 PRETTY HIGH AND YOU MAY HAVE 813 00:33:07,952 --> 00:33:11,189 OR KNOW PEOPLE IN YOUR DATASET 814 00:33:11,255 --> 00:33:13,825 WHO DROP OUT AND DIE IN SIX 815 00:33:13,891 --> 00:33:15,793 MONTHS BUT FOR THOSE WHO HAVE 816 00:33:15,860 --> 00:33:17,295 A LONGER TREATMENT, THIS MAY 817 00:33:17,362 --> 00:33:20,164 HAVE A REALLY LARGE IMPACT. 818 00:33:20,231 --> 00:33:23,835 IT DOESN'T BIAS THE STUDY, IT 819 00:33:23,901 --> 00:33:32,043 JUST IMPACTS WHO THE RESULTS 820 00:33:32,110 --> 00:33:32,443 ARE VIABLE. 821 00:33:32,510 --> 00:33:34,846 SO FOR DOCTORS TO USE THIS 822 00:33:34,912 --> 00:33:35,980 DATA ANALYSIS, IF YOU THINK 823 00:33:36,047 --> 00:33:38,383 ABOUT IT, THEY ARE TRYING TO 824 00:33:38,449 --> 00:33:39,350 MAKE TREATMENT DECISIONS AT 825 00:33:39,417 --> 00:33:40,118 THE TIME OF DIAGNOSIS. 826 00:33:40,184 --> 00:33:41,753 THEY DON'T KNOW IF THEIR 827 00:33:41,819 --> 00:33:44,155 PATIENT WILL DIE IN SIX MONTHS 828 00:33:44,222 --> 00:33:46,224 AND I MEAN IDEALLY THEY WON'T 829 00:33:46,290 --> 00:33:48,292 BUT THE DATA WE'RE GIVING THEM 830 00:33:48,359 --> 00:33:49,827 IS IF YOUR PATIENT LIVES AT 831 00:33:49,894 --> 00:33:51,929 LEAST SIX MONTHS AND UNDERGOES 832 00:33:51,996 --> 00:33:53,631 SURGERY DURING THAT TIME, HERE 833 00:33:53,698 --> 00:33:55,733 IS WHAT THEIR SURVIVAL LOOKS 834 00:33:55,800 --> 00:33:57,301 LIKE COMPARED TO THOSE WHO 835 00:33:57,368 --> 00:33:59,971 LIVE SIX MONTHS AND DON'T 836 00:34:00,037 --> 00:34:01,606 UNDERGO SURGERY AND IF YOU ARE 837 00:34:01,672 --> 00:34:04,375 TRYING TO MAKE A DECISION WITH 838 00:34:04,442 --> 00:34:05,877 TIME POINT ZERO, YOU DON'T 839 00:34:05,943 --> 00:34:07,111 ACTUALLY KNOW IF THEY ARE 840 00:34:07,178 --> 00:34:08,212 GOING TO LIVE THAT SIX MONTHS 841 00:34:08,279 --> 00:34:15,820 SO YOU MAY NOT BE SURE AND CAN 842 00:34:15,887 --> 00:34:18,289 APPLY THE DECISION-MAKING 843 00:34:18,356 --> 00:34:18,723 PRETTY TRICKY. 844 00:34:18,790 --> 00:34:20,892 SO BOTH THESE APPROACHES CAN 845 00:34:20,958 --> 00:34:24,595 ADJUST AND ACCOUNT FOR CENSOR 846 00:34:24,662 --> 00:34:26,798 OR IMMORTAL TIME BIAS, THEY 847 00:34:26,864 --> 00:34:30,134 INTRODUCE THE ISSUES WITH 848 00:34:30,201 --> 00:34:31,135 INTERPRETABILITY OF YOUR 849 00:34:31,202 --> 00:34:33,204 RESULTS. 850 00:34:33,271 --> 00:34:36,974 AS YOU CAN IMAGINE, CLONE 851 00:34:37,041 --> 00:34:38,976 CENSOR WEIGHTING DOES NOT HAVE 852 00:34:39,043 --> 00:34:39,510 THESE LIMITATIONS. 853 00:34:39,577 --> 00:34:41,846 WE HAVE A PROTOCOL WHERE WE'RE 854 00:34:41,913 --> 00:34:44,982 COMPARING THE EFFECTS OF 855 00:34:45,049 --> 00:34:46,884 TREATMENT AND THERE IS NO 856 00:34:46,951 --> 00:34:49,053 COMPARISON AND THEN AS YOU SAW 857 00:34:49,120 --> 00:34:50,788 IN THE FIGURES, WE START AT 858 00:34:50,855 --> 00:34:53,558 SIX MONTHS SO WE DON'T HAVE 859 00:34:53,624 --> 00:34:55,693 THE FORCED SURVIVAL FOR AN 860 00:34:55,760 --> 00:34:58,663 EXPECTED AMOUNT OF TIME IN OUR 861 00:34:58,729 --> 00:34:59,030 ANALYSIS. 862 00:34:59,096 --> 00:35:02,066 SO THIS IS ONE OF THE 863 00:35:02,133 --> 00:35:03,568 STRENGTHS COMPARED TO OTHER 864 00:35:03,634 --> 00:35:10,842 ANALYSES AND WHY I PREFER 865 00:35:10,908 --> 00:35:11,209 USING THE 866 00:35:11,275 --> 00:35:12,710 CLONE-CENSOR-WEIGHTING OVER 867 00:35:12,777 --> 00:35:13,911 THE OTHER APPROACHES. 868 00:35:13,978 --> 00:35:24,422 ANOTHER WAY THAT USING 869 00:35:27,658 --> 00:35:29,160 CLONE-CENSOR-WEIGHTING THAT IS 870 00:35:29,227 --> 00:35:32,163 HELPFUL IS YOU MIGHT BE 871 00:35:32,230 --> 00:35:34,098 THINKING MOST CANCER 872 00:35:34,165 --> 00:35:36,968 TREATMENTS AREN'T USUALLY A 873 00:35:37,034 --> 00:35:38,436 SINGLE ONE-TIME OCCURRENCE. 874 00:35:38,503 --> 00:35:42,874 THEY MIGHT BE HORMONAL 875 00:35:42,940 --> 00:35:44,175 INDEFINITELY OR SOMETHING THEY 876 00:35:44,242 --> 00:35:45,443 ARE ON FOR YEARS AND HOW DO 877 00:35:45,510 --> 00:35:47,612 YOU ANALYZE DATA WHEN YOU HAVE 878 00:35:47,678 --> 00:35:49,547 THESE COMPLEX TREATMENT 879 00:35:49,614 --> 00:35:49,914 PROTOCOLS? 880 00:35:49,981 --> 00:35:54,986 WELL, THE SHORT ANSWER IS TIME 881 00:35:55,052 --> 00:35:56,120 EXPOSURES CAN'T HANDLE IT 882 00:35:56,187 --> 00:35:58,523 UNLESS YOU ARE GOING TO TOGGLE 883 00:35:58,589 --> 00:36:00,625 BUT IT GETS VERY COMPLICATED. 884 00:36:00,691 --> 00:36:02,026 AND THE LANDMARK APPROACH, YOU 885 00:36:02,093 --> 00:36:03,661 CAN'T REQUIRE SOMEONE TO 886 00:36:03,728 --> 00:36:05,897 REMAIN ALIVE AND INCLUDED IN 887 00:36:05,963 --> 00:36:07,298 THE DATASET FOR POTENTIALLY 888 00:36:07,365 --> 00:36:08,566 YEARS IN ORDER TO CAPTURE ALL 889 00:36:08,633 --> 00:36:12,436 OF THE SPECIFIC THINGS THAT 890 00:36:12,503 --> 00:36:14,639 HAVE TO HAPPEN SO THEY CAN BE 891 00:36:14,705 --> 00:36:16,240 COMPLIANT FOR TREATMENT. 892 00:36:16,307 --> 00:36:19,110 SO HOPEFULLY AS I AM ALLUDING 893 00:36:19,176 --> 00:36:26,751 TO, YOU CAN CLONE THESE THINGS 894 00:36:26,817 --> 00:36:27,652 IN THE CLONE-CENSOR-WEIGHTING. 895 00:36:27,718 --> 00:36:29,854 AND I WON'T GO THROUGH ALL 896 00:36:29,921 --> 00:36:35,960 THESE BUT HERE IS AN EXAMPLE 897 00:36:36,027 --> 00:36:40,498 OF THE MULTISTEP OR MULTIMODAL 898 00:36:40,565 --> 00:36:41,766 TREATMENT APPROACH, YOU HAVE 899 00:36:41,832 --> 00:36:45,002 THOSE WHO HAVE BEEN CLONED BUT 900 00:36:45,069 --> 00:36:50,074 SENSORED AND THIS IS IN STEP 901 00:36:50,141 --> 00:36:55,413 2, THE COMPARISON OF CHEMO AND 902 00:36:55,479 --> 00:36:56,647 RADIATION WITH SURGERY VERSUS 903 00:36:56,714 --> 00:37:03,087 CHEMO SHOW AND RAID RADIATION 904 00:37:03,154 --> 00:37:04,589 WITHOUT SURGERY, NOBODY IS 905 00:37:04,655 --> 00:37:05,723 UNDERGOING NOTHING HERE AND 906 00:37:05,790 --> 00:37:07,191 EACH ONE OF THEM HAVE MULTIPLE 907 00:37:07,258 --> 00:37:12,830 STEPS AND AS YOU CAN SEE, THIS 908 00:37:12,897 --> 00:37:13,531 CLONE-CENSOR-WEIGHTING 909 00:37:13,598 --> 00:37:15,132 APPROACH CAN HANDLE THIS 910 00:37:15,199 --> 00:37:15,933 MULTISTEP PROCESS. 911 00:37:16,000 --> 00:37:18,569 ANOTHER THING THAT CAN HELP IS 912 00:37:18,636 --> 00:37:20,738 WITH WHAT WE REFER TO AS 913 00:37:20,805 --> 00:37:22,139 STATIC TREATMENT WHICH 914 00:37:22,206 --> 00:37:23,040 ESSENTIALLY MEANS THE 915 00:37:23,107 --> 00:37:24,342 TREATMENT IS DELIVERED OVER 916 00:37:24,408 --> 00:37:25,876 TIME BUT WHEN YOU DELIVER IT, 917 00:37:25,943 --> 00:37:26,978 IT IS KNOWN. 918 00:37:27,044 --> 00:37:31,983 SO IN THIS EXAMPLE YOU ARE 919 00:37:32,049 --> 00:37:34,619 LOOKING AT ANNUAL MAMMOGRAPHY. 920 00:37:34,685 --> 00:37:37,488 SO WOMEN UNDERGO ANNUAL 921 00:37:37,555 --> 00:37:39,757 MAMMOGRAPHY, THEY ARE GOING TO 922 00:37:39,824 --> 00:37:40,925 UNDERGO IT EVERY 12 MONTHS SO 923 00:37:40,992 --> 00:37:43,227 IF I GET MINE IN MAY, I AM 924 00:37:43,294 --> 00:37:44,829 GOING TO GET IT AROUND NEXT 925 00:37:44,895 --> 00:37:47,331 MAY AND THE NEXT MAY, ET 926 00:37:47,398 --> 00:37:47,665 CETERA. 927 00:37:47,732 --> 00:37:50,935 SO THIS CAN BE PROLONGED 928 00:37:51,002 --> 00:37:52,403 POTENTIALLY INDEFINITELY, THIS 929 00:37:52,470 --> 00:37:55,139 KIND OF STATIC TREATMENT BUT 930 00:37:55,206 --> 00:37:56,741 BECAUSE IT HAPPENS IN 12 931 00:37:56,807 --> 00:37:58,242 MONTHS, WE CAN KIND OF 932 00:37:58,309 --> 00:37:59,744 ANTICIPATE WHEN IT WILL OCCUR 933 00:37:59,810 --> 00:38:01,746 BUT AGAIN BETWEEN THE RAW DATA 934 00:38:01,812 --> 00:38:08,519 AND NEXT FIGURES, WE CAN BUILD 935 00:38:08,586 --> 00:38:09,220 IN CLONE-CENSOR-WEIGHTING TO 936 00:38:09,286 --> 00:38:10,588 ENABLE THESE KIND OF 937 00:38:10,655 --> 00:38:11,389 TREATMENTS. 938 00:38:11,455 --> 00:38:14,392 AND THEN WE CAN USE THEM TO 939 00:38:14,458 --> 00:38:16,694 HANDLE DYNAMIC TREATMENT 940 00:38:16,761 --> 00:38:17,261 STRATEGIES. 941 00:38:17,328 --> 00:38:17,862 SO DYNAMIC TREATMENT 942 00:38:17,928 --> 00:38:19,230 STRATEGIES IS WHEN THE 943 00:38:19,296 --> 00:38:21,766 DECISION TO UNDERGO TREATMENT 944 00:38:21,832 --> 00:38:25,069 IS INFLUENCED BY HEALTH STATUS 945 00:38:25,136 --> 00:38:26,370 OR THE DECISION OF THE PATIENT 946 00:38:26,437 --> 00:38:27,638 WHICH HAPPENS AT FOLLOW UP. 947 00:38:27,705 --> 00:38:30,174 SO THIS IS AN EXAMPLE OF MEN 948 00:38:30,241 --> 00:38:32,476 DIAGNOSED WITH PROSTATE CANCER 949 00:38:32,543 --> 00:38:34,178 AND WE'RE COMPARING WHETHER OR 950 00:38:34,245 --> 00:38:36,147 NOT THEY UNDERGO TREATMENT 951 00:38:36,213 --> 00:38:38,649 IMMEDIATELY SO WITHIN 90 DAYS 952 00:38:38,716 --> 00:38:41,085 OF DIAGNOSIS OR THEY DEFER 953 00:38:41,152 --> 00:38:43,220 TREATMENT UNTIL EITHER THEY 954 00:38:43,287 --> 00:38:44,221 SEE PROGRESSION OF THE 955 00:38:44,288 --> 00:38:46,791 DISEASE, SO THAT IS WHAT THE P 956 00:38:46,857 --> 00:38:48,392 STANDS FOR, THERE IS A CERTAIN 957 00:38:48,459 --> 00:38:50,828 TIME FRAME WHICH YOU WOULD 958 00:38:50,895 --> 00:38:52,329 UNDERGO TREATMENT OR IF THE 959 00:38:52,396 --> 00:38:54,765 DISEASE HAS BEEN PROGRESSED 960 00:38:54,832 --> 00:38:55,666 FOR THREE YEARS, YOU WOULD 961 00:38:55,733 --> 00:38:57,168 RECEIVE TREATMENT AT THE 962 00:38:57,234 --> 00:38:57,601 3-YEAR MARK. 963 00:38:57,668 --> 00:38:59,070 SO THIS IS VERY COMPLEX AND 964 00:38:59,136 --> 00:39:01,138 YOU HAVE TO MONITOR LEVELS BUT 965 00:39:01,205 --> 00:39:03,674 AGAIN AS YOU CAN HOPEFULLY SEE 966 00:39:03,741 --> 00:39:06,177 BY THESE FIGURES AND I AM 967 00:39:06,243 --> 00:39:08,546 HAPPY TO TAKE QUESTIONS ON 968 00:39:08,612 --> 00:39:09,180 THESE SPECIFIC APPROACHES, 969 00:39:09,246 --> 00:39:17,955 THIS IS THE WAY WE USE TO 970 00:39:18,022 --> 00:39:18,956 HANDLE THE MULTISTEP 971 00:39:19,023 --> 00:39:19,490 TREATMENTS AS WELL. 972 00:39:19,557 --> 00:39:22,093 SO NOW YOU CAN SEE THE 973 00:39:22,159 --> 00:39:26,397 APPROACH ON WIDE VARIETY OF 974 00:39:26,464 --> 00:39:28,132 STANDARDS, TREATMENTS, WAYS TO 975 00:39:28,199 --> 00:39:31,102 FOLD IN ENVIRONMENTAL AND 976 00:39:31,168 --> 00:39:32,103 UNINTENDED EXPOSURES AND 977 00:39:32,169 --> 00:39:33,204 ADDITIONALLY IF YOU ARE 978 00:39:33,270 --> 00:39:34,238 INTERESTED IN USING THIS 979 00:39:34,305 --> 00:39:35,773 APPROACH BUT HAVEN'T DONE IT 980 00:39:35,840 --> 00:39:39,143 BEFORE, THERE ARE RESOURCES 981 00:39:39,210 --> 00:39:40,311 AVAILABLE. 982 00:39:40,377 --> 00:39:42,379 TO ME ON, THE PAPER ON THE 983 00:39:42,446 --> 00:39:45,649 LUNG CANCER WE KIND OF TOUCHED 984 00:39:45,716 --> 00:39:46,884 ON EARLIER, ONE OF THE 985 00:39:46,951 --> 00:39:53,090 COAUTHORS OF THAT PAPER, SHE 986 00:39:53,157 --> 00:39:57,528 USED DATA CODES TO DO THE 987 00:39:57,595 --> 00:39:58,162 CLONE-CENSOR-WEIGHTING AND 988 00:39:58,229 --> 00:40:02,299 THEN ON THE OTHER STUDY OUR 989 00:40:02,366 --> 00:40:05,503 RESEARCH GROUP DID, WE USED 990 00:40:05,569 --> 00:40:09,974 SAS CODES TO DO THE 991 00:40:10,040 --> 00:40:10,808 CENSOR-WEIGHTING. 992 00:40:10,875 --> 00:40:14,411 SO THE TWO MOST COMMON CODING 993 00:40:14,478 --> 00:40:16,347 WITH SOFTWARE CAN HELP BUT 994 00:40:16,413 --> 00:40:18,949 EVEN HAVING THE CODING 995 00:40:19,016 --> 00:40:20,484 AVAILABLE CAN HELP YOU CODE IT 996 00:40:20,551 --> 00:40:22,086 IN OTHER PLATFORMS AS WELL. 997 00:40:22,153 --> 00:40:23,721 SO THERE ARE RESOURCES OUT 998 00:40:23,788 --> 00:40:24,855 THERE TO HELP YOU GET STARTED 999 00:40:24,922 --> 00:40:26,690 SO YOU DON'T HAVE TO START 1000 00:40:26,757 --> 00:40:27,391 FROM SCRATCH. 1001 00:40:27,458 --> 00:40:28,926 NOW TO KIND OF SUMMARIZE AND 1002 00:40:28,993 --> 00:40:31,595 WRAP THINGS UP SO WE HAVE TIME 1003 00:40:31,662 --> 00:40:32,429 FOR QUESTIONS, HOPEFULLY BY 1004 00:40:32,496 --> 00:40:36,534 NOW, WE ARE ALL ON THE SAME 1005 00:40:36,600 --> 00:40:37,568 PAGE WITH OBSERVATIONAL DATA 1006 00:40:37,635 --> 00:40:39,470 AND IT IS REALLY A CRITICAL 1007 00:40:39,537 --> 00:40:41,539 IMPORTANCE TO A POPULATION, 1008 00:40:41,605 --> 00:40:43,274 HOW IT ALLOWS US TO ASK 1009 00:40:43,340 --> 00:40:45,776 QUESTIONS OF A DIVERSE 1010 00:40:45,843 --> 00:40:48,245 POPULATION THAT ARE ALSO 1011 00:40:48,312 --> 00:40:51,682 INTERESTED IN HOW MINORITY AND 1012 00:40:51,749 --> 00:40:53,384 HEALTH DISPARITIES ARE ACUTELY 1013 00:40:53,450 --> 00:40:55,452 INTERESTED IN TO HELP ADDRESS 1014 00:40:55,519 --> 00:40:55,920 HEALTH EQUITY. 1015 00:40:55,986 --> 00:40:57,454 THERE IS ALSO A LOT OF 1016 00:40:57,521 --> 00:40:58,389 QUESTIONS WE'RE ASKING THAT 1017 00:40:58,455 --> 00:41:02,526 CAN'T BE DONE IN CLINICAL 1018 00:41:02,593 --> 00:41:03,794 TRIALS SO OBSERVATIONAL DATA 1019 00:41:03,861 --> 00:41:06,263 IS ALL WE'RE REALLY LEFT WITH. 1020 00:41:06,330 --> 00:41:12,469 HOWEVER, AS WE'RE HOPEFULLY 1021 00:41:12,536 --> 00:41:14,138 ALL AWARE, APPROPRIATE METHODS 1022 00:41:14,205 --> 00:41:17,141 ARE NEEDED TO ADDRESS 1023 00:41:17,208 --> 00:41:18,242 POTENTIAL BIASES, IMMORTAL 1024 00:41:18,309 --> 00:41:20,244 TIME, ET CETERA AND CAN HAVE A 1025 00:41:20,311 --> 00:41:22,780 MAJOR IMPACT ON RESULTS AND 1026 00:41:22,847 --> 00:41:24,281 CONCLUSIONS SO REALLY NEEDS TO 1027 00:41:24,348 --> 00:41:27,051 BE ADDRESSED AND HANDLED. 1028 00:41:27,117 --> 00:41:32,690 SO AS WE WALK THROUGH, THE 1029 00:41:32,756 --> 00:41:38,462 IMMORTAL TIME AND 1030 00:41:38,529 --> 00:41:40,364 CLONE-CENSOR-WEIGHTING ARE 1031 00:41:40,431 --> 00:41:43,067 THINGS WE USE IN THIS 1032 00:41:43,133 --> 00:41:44,235 OBSERVATIONAL DATA, CAN IT 1033 00:41:44,301 --> 00:41:47,538 ACCOUNT FOR TIME VARYING 1034 00:41:47,605 --> 00:41:49,240 CONFOUNDING AND CONTRA 1035 00:41:49,306 --> 00:41:50,875 INDICATIONS, IT DEPENDS ON HOW 1036 00:41:50,941 --> 00:41:52,810 THE STUDY IS DESIGNED AND I 1037 00:41:52,877 --> 00:41:54,545 BELIEVE IT CAN BE JUST AS 1038 00:41:54,612 --> 00:41:56,614 STRONG OR STRONGER BECAUSE OF 1039 00:41:56,680 --> 00:41:57,748 THE OBSERVATIONS WE CAN 1040 00:41:57,815 --> 00:41:59,483 INCLUDE IN THE DATA WHEN THE 1041 00:41:59,550 --> 00:42:01,018 CLINICAL TRIAL IS RUN 1042 00:42:01,085 --> 00:42:01,719 APPROPRIATELY. 1043 00:42:01,785 --> 00:42:04,455 AND WHILE I DIDN'T TOUCH ON IT 1044 00:42:04,521 --> 00:42:09,126 HERE, WE CAN ACCOUNT FOR THE 1045 00:42:09,193 --> 00:42:10,294 TIME-VARYING CONFOUNDING AND 1046 00:42:10,361 --> 00:42:11,629 IS SOME APPROACHES, YOU CAN'T 1047 00:42:11,695 --> 00:42:12,596 DO THAT. 1048 00:42:12,663 --> 00:42:18,669 YOU CAN BUILD FOR CONTRA 1049 00:42:18,736 --> 00:42:20,604 INDICATIONS AND BECAUSE YOU 1050 00:42:20,671 --> 00:42:23,340 ARE DRAFTING YOUR PROTOCOL, 1051 00:42:23,407 --> 00:42:27,044 YOU CAN INCLUDE THE 1052 00:42:27,111 --> 00:42:30,481 CONTRAINDICATIONS TO BE 1053 00:42:30,547 --> 00:42:34,018 INCLUDED IN YOUR STUDY, LIKE 1054 00:42:34,084 --> 00:42:35,519 IN THE MAMMOGRAPHY STUDY, 1055 00:42:35,586 --> 00:42:37,121 THOSE WITH BREAST CANCER WOULD 1056 00:42:37,187 --> 00:42:41,091 NO LONGER BE REQUIRED TO 1057 00:42:41,158 --> 00:42:44,194 UNDERGO MAMMOGRAPHY BUT STILL 1058 00:42:44,261 --> 00:42:46,363 NEED TO BE INCLUDED IN THE 1059 00:42:46,430 --> 00:42:47,498 TREATMENT STRATEGY. 1060 00:42:47,564 --> 00:42:54,171 SO YOU CAN BUILD THOSE IN ON A 1061 00:42:54,238 --> 00:42:57,141 TARGET TRIAL EMULATION WITH 1062 00:42:57,207 --> 00:42:59,710 ALL THOSE VARIANCES THAT 1063 00:42:59,777 --> 00:43:00,044 OCCUR. 1064 00:43:00,110 --> 00:43:02,146 AND SO LIKE AGAIN WITH 1065 00:43:02,212 --> 00:43:03,881 MAMMOGRAPHY, WHEN IS THAT 1066 00:43:03,948 --> 00:43:06,317 USEFUL, DOES IT OCCUR IN THE 1067 00:43:06,383 --> 00:43:07,818 CLINICAL SETTING, SO WE NEED 1068 00:43:07,885 --> 00:43:09,787 TO BUILD THOSE THINGS THAT 1069 00:43:09,853 --> 00:43:11,388 OCCUR, YOU KNOW, THESE EVENTS 1070 00:43:11,455 --> 00:43:13,958 THAT HAPPEN INTO OUR DATA AS 1071 00:43:14,024 --> 00:43:14,258 WELL. 1072 00:43:14,325 --> 00:43:16,727 YOU KNOW, IT IS NOT USEFUL TO 1073 00:43:16,794 --> 00:43:18,729 EXCLUDE THEM IN OUR DIAGNOSIS 1074 00:43:18,796 --> 00:43:20,764 FOR CANCER, FOR EXAMPLE, WHEN 1075 00:43:20,831 --> 00:43:28,639 LOOKING AT CANCER SCREENING AS 1076 00:43:28,706 --> 00:43:35,746 AN EFFECTIVE TOOL TO DETERMINE 1077 00:43:35,813 --> 00:43:40,150 WHETHER IT WEIGHED IN 1078 00:43:40,217 --> 00:43:41,318 MORTALITY. 1079 00:43:41,385 --> 00:43:45,055 AND THEN FINALLY THESE METHODS 1080 00:43:45,122 --> 00:43:49,693 USED AS AN ESTIMATE OF REAL 1081 00:43:49,760 --> 00:43:51,362 TREATMENT STRATEGIES, YOU 1082 00:43:51,428 --> 00:43:54,398 DON'T HAVE THE CAVEATS OF WHAT 1083 00:43:54,465 --> 00:43:56,834 DAYS ARE YOU UNDERGOING 1084 00:43:56,900 --> 00:43:58,969 SURGERY, WHAT DOES IT MEAN TO 1085 00:43:59,036 --> 00:44:01,605 KNOW ONLY THE RESULT IN THE 1086 00:44:01,672 --> 00:44:02,406 PATIENT POPULATION THAT 1087 00:44:02,473 --> 00:44:05,809 SURVIVED ONLY SIX MONTHS SO 1088 00:44:05,876 --> 00:44:07,244 THE QUESTIONS CAN BE DIRECTLY 1089 00:44:07,311 --> 00:44:10,781 APPLIED TO THE CLINICAL STUDY 1090 00:44:10,848 --> 00:44:12,583 AND HOPEFULLY IMPROVE CLINICAL 1091 00:44:12,649 --> 00:44:13,317 DECISION-MAKING ON THE 1092 00:44:13,384 --> 00:44:15,719 TREATMENT OF PATIENTS AND 1093 00:44:15,786 --> 00:44:17,187 HOPEFULLY WHEN APPLIED WITH 1094 00:44:17,254 --> 00:44:19,123 THE HEALTH EQUITY LENS CAN 1095 00:44:19,189 --> 00:44:20,557 HELP ADDRESS HEALTH EQUITY. 1096 00:44:20,624 --> 00:44:22,059 AND WITH THAT, I AM GOING TO 1097 00:44:22,126 --> 00:44:22,693 STOP TALKING. 1098 00:44:22,760 --> 00:44:29,566 I WANT TO QUICKLY ACKNOWLEDGE 1099 00:44:29,633 --> 00:44:34,104 NIMHCD THAT FUNDS MY WORK AND 1100 00:44:34,171 --> 00:44:44,381 THE INTERNATIONAL SOCIETY OF 1101 00:44:44,448 --> 00:44:46,417 PHARMACOEPIDEMIOLOGY USING THE 1102 00:44:46,483 --> 00:44:49,286 GRAPHICS YOU SAW BASED OFF 1103 00:44:49,353 --> 00:44:50,654 CHICKEN SCRATCH DRAWINGS IN 1104 00:44:50,721 --> 00:44:52,156 NOTEBOOKS THAT WE STARTED WITH 1105 00:44:52,222 --> 00:44:55,359 AND THEN THE ISPE CANCER 1106 00:44:55,426 --> 00:44:57,694 SPECIAL INTEREST GROUP THAT 1107 00:44:57,761 --> 00:44:59,029 PROVIDED USEFUL FEEDBACK. 1108 00:44:59,096 --> 00:45:00,864 AND THEN EVERYONE ON THE LEFT 1109 00:45:00,931 --> 00:45:02,699 ARE MY COAUTHORS ON THIS PAPER 1110 00:45:02,766 --> 00:45:04,401 THAT I WOULD LIKE TO 1111 00:45:04,468 --> 00:45:05,869 ACKNOWLEDGE AND IT IS 1112 00:45:05,936 --> 00:45:11,842 CURRENTLY UNDER REVIEW BUT 1113 00:45:11,909 --> 00:45:14,778 HOPEFULLY OUR PAPER WILL BE 1114 00:45:14,845 --> 00:45:15,846 OUT IN PUBLISHING SOON AND YOU 1115 00:45:15,913 --> 00:45:19,483 WILL BE ABLE TO REVIEW THIS IN 1116 00:45:19,550 --> 00:45:24,588 MORE DEPTH AND START USING 1117 00:45:24,655 --> 00:45:25,522 CLONE-CENSOR-WEIGHTING IN YOUR 1118 00:45:25,589 --> 00:45:26,690 OWN RESEARCH. 1119 00:45:26,757 --> 00:45:27,524 THESE ARE MY REFERENCES AND 1120 00:45:27,591 --> 00:45:28,759 WITH THAT I WILL TAKE 1121 00:45:28,826 --> 00:45:30,360 QUESTIONS AND FEEL FREE TO 1122 00:45:30,427 --> 00:45:32,563 E-MAIL ME LATER IF YOU WANT TO 1123 00:45:32,629 --> 00:45:34,264 DISCUSS FURTHER ANY OF THIS 1124 00:45:34,331 --> 00:45:37,468 THAT I HAVE HERE. 1125 00:45:37,534 --> 00:45:39,503 >> EXCELLENT, THANK YOU, THAT 1126 00:45:39,570 --> 00:45:41,572 WAS AN EXCELLENT PRESENTATION, 1127 00:45:41,638 --> 00:45:43,307 PAULA AND I THINK THESE 1128 00:45:43,373 --> 00:45:46,677 METHODS COULD BE REALLY USEFUL 1129 00:45:46,743 --> 00:45:47,578 FOR OBSERVATIONAL STUDIES. 1130 00:45:47,644 --> 00:45:49,947 SO WHILE I WAIT FOR THE 1131 00:45:50,013 --> 00:45:51,248 AUDIENCE TO SUBMIT THEIR 1132 00:45:51,315 --> 00:45:54,718 QUESTIONS, I WILL PUT THE LINK 1133 00:45:54,785 --> 00:45:55,919 ON THE SCREEN AND ASK YOU A 1134 00:45:55,986 --> 00:45:57,888 QUESTION OF MY OWN. 1135 00:45:57,955 --> 00:46:02,726 WHAT ARE SOME OF THE 1136 00:46:02,793 --> 00:46:04,027 LIMITATIONS OF HOW -- 1137 00:46:04,094 --> 00:46:04,695 [INDISCERNIBLE] 1138 00:46:04,761 --> 00:46:08,365 >> I THINK THE BIGGEST 1139 00:46:08,432 --> 00:46:12,836 LIMITATIONS WITH OBSERVATIONAL 1140 00:46:12,903 --> 00:46:13,303 STUDIES WITH 1141 00:46:13,370 --> 00:46:13,971 CLONE-CENSOR-WEIGHTING IS 1142 00:46:14,037 --> 00:46:15,072 GOING TO BE THE DATA. 1143 00:46:15,139 --> 00:46:17,307 YOU NEED TO KNOW THE TIMING OF 1144 00:46:17,374 --> 00:46:19,309 THE TREATMENTS TO BE ABLE TO 1145 00:46:19,376 --> 00:46:21,678 FOCUS ON THEM WHEN THEY 1146 00:46:21,745 --> 00:46:24,815 DEVIATE AND NOT ALL DATASETS 1147 00:46:24,882 --> 00:46:27,484 INCLUDE THAT KIND OF 1148 00:46:27,551 --> 00:46:28,252 DELINEATION. 1149 00:46:28,318 --> 00:46:31,288 SO FOR EXAMPLE, IN A CANCER 1150 00:46:31,355 --> 00:46:33,490 STUDY, IF A PATIENT UNDERGOES 1151 00:46:33,557 --> 00:46:35,792 SURGERY AND THEN UNDERGOES 1152 00:46:35,859 --> 00:46:37,060 CHEMO AND RADIATION, IF YOU 1153 00:46:37,127 --> 00:46:39,830 DON'T SAY WHEN IT HAPPENED, 1154 00:46:39,897 --> 00:46:41,465 YOU CAN'T USE THESE APPROACHES 1155 00:46:41,532 --> 00:46:43,834 IN YOUR STUDY ALTHOUGH IT MAY 1156 00:46:43,901 --> 00:46:45,602 BE PART OF THE DESIGN TO NOT 1157 00:46:45,669 --> 00:46:53,177 LOOK AT TREATMENT IN YOUR 1158 00:46:53,243 --> 00:46:53,844 DATA. 1159 00:46:53,911 --> 00:46:56,914 SO ANY KIND OF DATA, NOT JUST 1160 00:46:56,980 --> 00:47:00,017 TREATMENT BUT CLINICAL CENTER 1161 00:47:00,083 --> 00:47:03,086 DATA, CLINICAL CENTER AT A 1162 00:47:03,153 --> 00:47:05,956 HOSPITAL, KINDS OF 1163 00:47:06,023 --> 00:47:06,757 ADMINISTRATIVE, INSURANCE, 1164 00:47:06,823 --> 00:47:08,525 MEDICARE, MEDICAID, ALL OF 1165 00:47:08,592 --> 00:47:09,560 THESE DATA SOURCES INCLUDE 1166 00:47:09,626 --> 00:47:10,727 TREATMENT INFORMATION WE NEED 1167 00:47:10,794 --> 00:47:13,263 TO DO THIS BUT YEAH, DATA, I 1168 00:47:13,330 --> 00:47:15,365 WOULD SAY, AND HAVING THE 1169 00:47:15,432 --> 00:47:17,668 VARIABLES IN DATA ARE REALLY 1170 00:47:17,734 --> 00:47:20,871 THE ONE LIMITATION I WOULD SAY 1171 00:47:20,938 --> 00:47:23,006 TO APPLYING THIS. 1172 00:47:23,073 --> 00:47:26,777 >> YEAH, I THINK THAT'S A 1173 00:47:26,843 --> 00:47:28,645 PROBLEM WITH THE DATA. 1174 00:47:28,712 --> 00:47:29,746 THANK YOU. 1175 00:47:29,813 --> 00:47:31,415 SO WHILE WAITING FOR OTHER 1176 00:47:31,481 --> 00:47:33,183 QUESTIONS, I HAVE ANOTHER 1177 00:47:33,250 --> 00:47:34,318 QUESTION FOR YOU. 1178 00:47:34,384 --> 00:47:40,724 CAN TARGET TRIAL EMULATION 1179 00:47:40,791 --> 00:47:41,491 INFLUENCE 1180 00:47:41,558 --> 00:47:42,159 CLONE-CENSOR-WEIGHTING OF 1181 00:47:42,226 --> 00:47:42,526 RESEARCH? 1182 00:47:42,593 --> 00:47:43,894 >> YES, AND I WILL SAY TO 1183 00:47:43,961 --> 00:47:47,631 DATE -- AND I TRIED TO FIND 1184 00:47:47,698 --> 00:47:50,067 EXAMPLES OF THIS, WAS IN TOUCH 1185 00:47:50,133 --> 00:47:51,468 WITH SEVERAL COAUTHORS OF THAT 1186 00:47:51,535 --> 00:47:53,971 PAPER, IT DOESN'T LOOK LIKE IT 1187 00:47:54,037 --> 00:47:58,542 HAS BEEN USED TO DATE WITH 1188 00:47:58,609 --> 00:47:59,476 HEALTH DISPARITIES EXPLICITLY. 1189 00:47:59,543 --> 00:48:04,348 SO IN THE ONE PAPER, LUNG 1190 00:48:04,414 --> 00:48:06,883 CANCER SURGERY LOOKING AT 1191 00:48:06,950 --> 00:48:08,785 OLDER ADULTS WHO WERE EXCLUDED 1192 00:48:08,852 --> 00:48:10,187 FROM THE TRIALS WHEN LOOKING 1193 00:48:10,254 --> 00:48:12,623 AT THE EFFECTS OF SURGERY ON 1194 00:48:12,689 --> 00:48:13,790 SURVIVAL AND HOPEFULLY WHILE 1195 00:48:13,857 --> 00:48:17,027 CLINICAL TRIALS ARE NOT 1196 00:48:17,094 --> 00:48:19,663 EXCLUDING RACIAL OR ETHNIC 1197 00:48:19,730 --> 00:48:21,265 POPULATIONS, THEY MAY BE 1198 00:48:21,331 --> 00:48:22,766 EXCLUDING THEM BASED ON ACCESS 1199 00:48:22,833 --> 00:48:24,434 TO TRIALS AND THE CLINICAL 1200 00:48:24,501 --> 00:48:26,937 TRIALS THAT ARE INCLUDED SO WE 1201 00:48:27,004 --> 00:48:29,573 CAN CONDUCT STUDIES LOOKING AT 1202 00:48:29,640 --> 00:48:32,075 THIS APPROACH AND 1203 00:48:32,142 --> 00:48:32,876 EFFECTIVENESS TO CANCER 1204 00:48:32,943 --> 00:48:34,177 TREATMENTS IN THE SMALLER 1205 00:48:34,244 --> 00:48:35,279 POPULATION IF YOU ARE 1206 00:48:35,345 --> 00:48:37,147 INTERESTED IN ORDER TO MAKE 1207 00:48:37,214 --> 00:48:38,749 THE POPULATIONS MORE DIVERSE 1208 00:48:38,815 --> 00:48:41,151 AND TO MAKE SURE THAT WE'RE 1209 00:48:41,218 --> 00:48:44,688 LOOKING AT THE EFFECTS OF THIS 1210 00:48:44,755 --> 00:48:46,290 POPULATION OR EFFECTS OF THESE 1211 00:48:46,356 --> 00:48:50,594 TREATMENTS ON THE POPULATION. 1212 00:48:50,661 --> 00:48:54,665 >> AND CAN THESE FACTORS ALSO 1213 00:48:54,731 --> 00:48:56,733 SHOW DETERMINANTS OF HEALTH? 1214 00:48:56,800 --> 00:48:59,169 >> YEAH, I THINK THIS METHOD 1215 00:48:59,236 --> 00:49:00,170 IS RELATIVELY NEW BUT THERE IS 1216 00:49:00,237 --> 00:49:03,173 A LOT OF THINGS WE LOOK AT. 1217 00:49:03,240 --> 00:49:04,141 SOCIAL DETERMINANTS OF HEALTH 1218 00:49:04,207 --> 00:49:06,943 WHERE THERE IS A SIGNIFICANT 1219 00:49:07,010 --> 00:49:08,912 LINE, FOR EXAMPLE, WHEN WE 1220 00:49:08,979 --> 00:49:12,282 COMMONLY LOOK AT PAPERS, WE 1221 00:49:12,349 --> 00:49:14,951 LOOK AT EDUCATION ON LIFE 1222 00:49:15,018 --> 00:49:15,519 EXPECTANCY OR OVERALL 1223 00:49:15,585 --> 00:49:18,422 SURVIVAL, WHAT WE DO IS LOOK 1224 00:49:18,488 --> 00:49:22,025 AT LIFE EXPECTANCY AT AGE 25 1225 00:49:22,092 --> 00:49:24,428 AND THEN CAPTURE EDUCATION AT 1226 00:49:24,494 --> 00:49:26,496 25 WHICH ESSENTIALLY IS DOING 1227 00:49:26,563 --> 00:49:28,899 A LANDMARK APPROACH IN THESE 1228 00:49:28,965 --> 00:49:29,900 KIND OF ANALYSES. 1229 00:49:29,966 --> 00:49:32,969 BUT YOU KNOW THE SURVIVAL 1230 00:49:33,036 --> 00:49:35,272 DOESN'T -- NOT EVERYONE LIVES 1231 00:49:35,339 --> 00:49:36,306 TILL AGE 25. 1232 00:49:36,373 --> 00:49:37,574 UNFORTUNATELY THERE ARE 1233 00:49:37,641 --> 00:49:38,775 CHILDHOOD CANCER AND OTHER 1234 00:49:38,842 --> 00:49:39,242 DISEASES. 1235 00:49:39,309 --> 00:49:40,344 THERE IS ALSO A LOT OF OTHER 1236 00:49:40,410 --> 00:49:43,347 THINGS THAT I WOULD SAY HAVE 1237 00:49:43,413 --> 00:49:45,749 STRUCTURAL RACISM AND OTHER 1238 00:49:45,816 --> 00:49:48,919 INEQUITIES THAT HAVE A HUGE 1239 00:49:48,985 --> 00:49:52,356 IMPACT ON THAT CAN CAUSE 1240 00:49:52,422 --> 00:49:53,824 MORTALITY IN CHILDHOOD AND 1241 00:49:53,890 --> 00:49:55,559 EARLY ADULTHOOD THAT WE DON'T 1242 00:49:55,625 --> 00:49:57,194 GET TO INCORPORATE IN THESE 1243 00:49:57,260 --> 00:49:58,729 STUDIES BECAUSE WE START AT 1244 00:49:58,795 --> 00:49:59,496 25. 1245 00:49:59,563 --> 00:50:01,665 YOU KNOW THINGS LIKE 1246 00:50:01,732 --> 00:50:03,633 EXPERIENCES WITH STRUCTURAL 1247 00:50:03,700 --> 00:50:05,001 RACISM, THEY START AT BIRTH 1248 00:50:05,068 --> 00:50:13,710 BUT WE MAY NOT BE CAP THAT 1249 00:50:13,777 --> 00:50:15,112 CAPTURING OR APPROACHING THEM. 1250 00:50:15,178 --> 00:50:18,648 SO THERE IS A LOT OF SPACE TO 1251 00:50:18,715 --> 00:50:21,918 LOOK AT THESE TRADITIONAL 1252 00:50:21,985 --> 00:50:23,653 METHODS AND A LOT OF THE 1253 00:50:23,720 --> 00:50:25,455 PAPERS AND ALL OF THE PAPERS 1254 00:50:25,522 --> 00:50:27,324 REALLY THAT I FOUND THAT USED 1255 00:50:27,391 --> 00:50:31,261 THIS METHOD HAVE FOCUSED ON 1256 00:50:31,328 --> 00:50:33,430 TREATMENT, SO MEDICATION, 1257 00:50:33,497 --> 00:50:34,131 TREATMENT, CHEMO, RADIATION, 1258 00:50:34,197 --> 00:50:36,967 THOSE KIND OF THINGS AND 1259 00:50:37,033 --> 00:50:38,135 HAVEN'T REALLY LOOKED AT THE 1260 00:50:38,201 --> 00:50:38,735 EXPOSURE. 1261 00:50:38,802 --> 00:50:39,770 BUT I THINK THAT IS AN 1262 00:50:39,836 --> 00:50:43,073 INTERESTING PLACE TO TAKE THIS 1263 00:50:43,140 --> 00:50:44,641 NEXT. 1264 00:50:44,708 --> 00:50:46,610 >> YEAH, I DEFINITELY AGREE 1265 00:50:46,676 --> 00:50:48,311 AND MY WORK HAS SHOWN THAT 1266 00:50:48,378 --> 00:50:48,612 ALSO. 1267 00:50:48,678 --> 00:50:50,781 SO I WAS GOING TO ASK YOU HOW 1268 00:50:50,847 --> 00:50:54,851 I COULD APPLY THAT METHOD BUT 1269 00:50:54,918 --> 00:50:57,788 THAT MIGHT BE A LONG 1270 00:50:57,854 --> 00:50:58,221 CONVERSATION. 1271 00:50:58,288 --> 00:51:01,425 >> YEAH, BUT I THINK ANY TIME 1272 00:51:01,491 --> 00:51:07,364 WHERE YOUR EXPOSURE OR WHERE 1273 00:51:07,431 --> 00:51:10,133 YOU ARE EMBOLDENING PEOPLE AND 1274 00:51:10,200 --> 00:51:11,868 MEASURE THEIR EXPOSURE AT A 1275 00:51:11,935 --> 00:51:13,570 SECOND DATE, SO A SECOND 1276 00:51:13,637 --> 00:51:15,372 WEIGHTING OF THE STUDY 1277 00:51:15,439 --> 00:51:17,307 COLLECTION DATA IF YOU HAVE 1278 00:51:17,374 --> 00:51:18,842 SOME OF THESE COPORT STUDIES 1279 00:51:18,909 --> 00:51:20,677 AND WHAT NOT, IF YOU ONLY 1280 00:51:20,744 --> 00:51:22,078 RESTRICT IT TO PEOPLE WHO 1281 00:51:22,145 --> 00:51:24,714 PARTICIPATE IN THE SECOND 1282 00:51:24,781 --> 00:51:27,918 WEIGHTING, PAW BE INTRODUCING 1283 00:51:27,984 --> 00:51:29,085 IMMORTAL TIME IN YOUR STUDIES. 1284 00:51:29,152 --> 00:51:31,154 SO IT IS DEFINITELY A PLACE I 1285 00:51:31,221 --> 00:51:37,494 CAN SAY IT IS HELPFUL. 1286 00:51:37,561 --> 00:51:40,263 I THINK HAVING THE MEASURES TO 1287 00:51:40,330 --> 00:51:43,533 APPROPRIATELY CAPTURE SOME OF 1288 00:51:43,600 --> 00:51:44,701 THESE DETERMINANTS AND 1289 00:51:44,768 --> 00:51:46,436 DETERMINANTS OF HEALTH WILL BE 1290 00:51:46,503 --> 00:51:48,038 AN ISSUE BUT WHERE WE HAVE 1291 00:51:48,104 --> 00:51:53,043 THAT DATA, WE CAN START 1292 00:51:53,109 --> 00:51:57,013 CONDUCTING THESE QUESTIONS, 1293 00:51:57,080 --> 00:51:58,715 WHERE THEY ARE A LITTLE 1294 00:51:58,782 --> 00:52:00,317 STRONGER INSTEAD OF JUST 1295 00:52:00,383 --> 00:52:02,819 LIMITING WHERE WE ASK THE 1296 00:52:02,886 --> 00:52:05,655 QUESTIONS, BECAUSE THERE'S 1297 00:52:05,722 --> 00:52:06,656 STRUCTURAL RACISM IN 1298 00:52:06,723 --> 00:52:07,624 CARDIOVASCULAR DISEASE FOR 1299 00:52:07,691 --> 00:52:10,760 EXAMPLE IN YOUR RESEARCH TO IS 1300 00:52:10,827 --> 00:52:12,762 IT ASSOCIATED WITH 1301 00:52:12,829 --> 00:52:15,866 CARDIOVASCULAR DISEASE AND THE 1302 00:52:15,932 --> 00:52:17,667 WITH A STRONGER EVIDENCE, 1303 00:52:17,734 --> 00:52:20,637 HOPEFULLY WE WILL BE ABLE TO 1304 00:52:20,704 --> 00:52:21,371 INTERVENE IN THE POLICIES AND 1305 00:52:21,438 --> 00:52:24,274 THERE WILL BE LESS PUSHBACK ON 1306 00:52:24,341 --> 00:52:26,343 WELL IT COULD BE THIS OR THIS 1307 00:52:26,409 --> 00:52:28,445 BUT NOBODY IS PUSHING BACK ON 1308 00:52:28,512 --> 00:52:34,251 A CLINICAL TRIAL WHEN WHEN -- 1309 00:52:34,317 --> 00:52:40,490 WHEN YOU SAY THIS TREATMENT 1310 00:52:40,557 --> 00:52:42,726 CAN HELP AS SHOWN IN CLINICAL 1311 00:52:42,792 --> 00:52:45,795 TRIALS SO HOPEFULLY WHEN WE 1312 00:52:45,862 --> 00:52:46,997 LOOK AT OBSERVATIONAL DATA, IT 1313 00:52:47,063 --> 00:52:48,732 CAN DO THE SAME THING. 1314 00:52:48,798 --> 00:52:49,299 >> ABSOLUTELY. 1315 00:52:49,366 --> 00:52:51,635 AND ANOTHER QUESTION FOR YOU, 1316 00:52:51,701 --> 00:52:54,671 I KNOW YOU MENTIONED HOW THESE 1317 00:52:54,738 --> 00:52:56,640 METHODS ARE APPLIED BY HOW 1318 00:52:56,706 --> 00:53:00,410 ABOUT YOU, HOW DO YOU USE 1319 00:53:00,477 --> 00:53:01,978 THESE METHODS IN YOUR 1320 00:53:02,045 --> 00:53:02,412 RESEARCH? 1321 00:53:02,479 --> 00:53:03,914 >> YEAH, THAT IS ONE THING 1322 00:53:03,980 --> 00:53:09,152 THAT I DUG INTO MY RESEARCH 1323 00:53:09,219 --> 00:53:11,121 WHICH WAS HEALTHCARE OUTCOMES. 1324 00:53:11,187 --> 00:53:18,628 SO LOOKING AT THE CANCER BASE, 1325 00:53:18,695 --> 00:53:20,497 THERE ARE PLACES TO GO AND 1326 00:53:20,564 --> 00:53:23,900 THEN ALSO LOOKING AT HOW 1327 00:53:23,967 --> 00:53:25,535 NEIGHBORHOOD EFFECTS AND 1328 00:53:25,602 --> 00:53:27,237 CHILDHOOD EXPOSURES AND KIND 1329 00:53:27,304 --> 00:53:32,509 OF THESE LONG EXPOSURES TO 1330 00:53:32,576 --> 00:53:33,777 RACISM AND ENVIRONMENTAL 1331 00:53:33,843 --> 00:53:37,447 FACTORS THAT OCCUR MORE LIKELY 1332 00:53:37,514 --> 00:53:40,817 IN FORMAL NEIGHBORHOODS, HOW 1333 00:53:40,884 --> 00:53:42,319 THEY AFFECT BOTH THE TREATMENT 1334 00:53:42,385 --> 00:53:44,287 OF INDIVIDUALS AND THEIR 1335 00:53:44,354 --> 00:53:45,188 OUTCOMES AS WELL. 1336 00:53:45,255 --> 00:53:49,960 SO I THINK MY NEXT STEP AS I 1337 00:53:50,026 --> 00:53:53,496 KEEP ALLUDING TO AS WE MOVE 1338 00:53:53,563 --> 00:54:01,171 THESE METHODS INTO A FOCUSED 1339 00:54:01,237 --> 00:54:02,539 HEALTH DISPARITY -- 1340 00:54:02,606 --> 00:54:03,006 [INDISCERNIBLE] 1341 00:54:03,073 --> 00:54:04,274 >> WHY DO YOU THINK THAT IS, 1342 00:54:04,341 --> 00:54:06,710 WHY DO YOU THINK IT HAS NOT 1343 00:54:06,776 --> 00:54:09,646 GONE THERE YET, WITH HEALTH 1344 00:54:09,713 --> 00:54:10,246 DISPARITIES? 1345 00:54:10,313 --> 00:54:12,749 >> YEAH, I THINK -- MY GUESS 1346 00:54:12,816 --> 00:54:15,385 IS THAT LIKE WHEN IT COMES TO 1347 00:54:15,452 --> 00:54:18,221 A LOT OF THESE CAUSAL METHODS 1348 00:54:18,288 --> 00:54:20,457 WE'RE TALKING ABOUT, A LOT OF 1349 00:54:20,523 --> 00:54:26,196 THEM POP UP IN 1350 00:54:26,262 --> 00:54:27,664 PHARMACOEPIDEMIOLOGY AND JUST 1351 00:54:27,731 --> 00:54:30,300 OUT OF NECESSITY, FOR HIV 1352 00:54:30,367 --> 00:54:33,503 CARE, YOU GIVE THEM ANTIVIRALS 1353 00:54:33,570 --> 00:54:34,771 THAT AFFECT THEIR VIRAL LOAD 1354 00:54:34,838 --> 00:54:35,839 AND THEN MODIFY THEIR 1355 00:54:35,905 --> 00:54:37,674 TREATMENT BASED ON THEIR 1356 00:54:37,741 --> 00:54:38,475 RESPONSE. 1357 00:54:38,541 --> 00:54:41,978 IF THEY ARE NOT RESPONDING, 1358 00:54:42,045 --> 00:54:43,947 YOU FIND DIFFERENT TREATMENT 1359 00:54:44,014 --> 00:54:45,315 STRATEGIES AND IF THEY ARE, 1360 00:54:45,382 --> 00:54:47,884 THEN YOU KEEP THEM ON IT. 1361 00:54:47,951 --> 00:54:51,154 SO IT BECAME AWARE IN THE 1362 00:54:51,221 --> 00:54:53,123 RESEARCH SPACE THAT OUR 1363 00:54:53,189 --> 00:54:53,923 TREATMENT IMPACTS FUTURE 1364 00:54:53,990 --> 00:54:55,091 MEASURES AND THERE ARE SOME 1365 00:54:55,158 --> 00:54:56,760 THINGS YOU CAN'T DO 1366 00:54:56,826 --> 00:54:59,295 ANALYTICALLY BECAUSE IT IS 1367 00:54:59,362 --> 00:55:06,136 VERY OBVIOUS. 1368 00:55:06,202 --> 00:55:07,871 PHARMACOEPIDEMIOLOGY IS VERY 1369 00:55:07,937 --> 00:55:09,172 OBVIOUS WHERE EVERYONE HAS TO 1370 00:55:09,239 --> 00:55:12,308 LIVE SIX MONTHS TO BE ABLE TO 1371 00:55:12,375 --> 00:55:15,545 OBSERVE IT SO IF THERE IS NO 1372 00:55:15,612 --> 00:55:17,981 AVERAGE SURVIVAL, WHERE DO WE 1373 00:55:18,048 --> 00:55:19,149 SEE IMPROVEMENT. 1374 00:55:19,215 --> 00:55:22,218 SO IF YOU TAKE FOUR MONTHS TO 1375 00:55:22,285 --> 00:55:25,021 UNDERGO SURGERY, YOU WILL SEE 1376 00:55:25,088 --> 00:55:25,722 A FOUR-MONTH SURVIVAL. 1377 00:55:25,789 --> 00:55:28,591 SO OUT OF NECESSITY, THEY 1378 00:55:28,658 --> 00:55:29,192 DEVELOP THESE METHODS. 1379 00:55:29,259 --> 00:55:32,495 I THINK SOME OF THIS CAN BE 1380 00:55:32,562 --> 00:55:35,365 HARDER TO CONCEPTUALIZE IN 1381 00:55:35,432 --> 00:55:36,299 HEALTH DISPARITY RESEARCH AND 1382 00:55:36,366 --> 00:55:39,202 ALSO THE LACK OF ABILITY TO 1383 00:55:39,269 --> 00:55:40,904 MEASURE APPROPRIATELY, YOU 1384 00:55:40,970 --> 00:55:42,338 KNOW, OVER A TIME POINT. 1385 00:55:42,405 --> 00:55:45,675 WE DO A LOT OF CROSS-SECTIONAL 1386 00:55:45,742 --> 00:55:47,043 DATA BUT I THINK WITH THIS 1387 00:55:47,110 --> 00:55:50,714 PUSH OF REAL WORLD DATA AND 1388 00:55:50,780 --> 00:55:51,881 BIG DATA, LOOKS LIKE WE ARE 1389 00:55:51,948 --> 00:55:54,384 USING IT ALL THE TIME FOR 1390 00:55:54,451 --> 00:55:59,456 RESEARCH SO I THINK THE DATA 1391 00:55:59,522 --> 00:56:01,157 LIMITATION FOR THOSE WITH 1392 00:56:01,224 --> 00:56:02,759 HEALTH DISPARITIES IS NO 1393 00:56:02,826 --> 00:56:04,327 LONGER AN ISSUE AND WE'RE ABLE 1394 00:56:04,394 --> 00:56:07,630 TO SEE MORE BROADLY, GLOBALLY 1395 00:56:07,697 --> 00:56:09,299 AND CAUSALLY AT OUR RESEARCH 1396 00:56:09,365 --> 00:56:12,902 WHEN WE START IMPLEMENTING 1397 00:56:12,969 --> 00:56:14,971 CAUSAL METHODS AND THAT HAS 1398 00:56:15,038 --> 00:56:16,606 EVOLVED IN OTHER AREAS OF THE 1399 00:56:16,673 --> 00:56:17,607 POPULATION INTO OUR WORK. 1400 00:56:17,674 --> 00:56:18,942 >> AND YOU WERE THE FIRST, 1401 00:56:19,008 --> 00:56:20,577 RIGHT, TO USE THIS METHOD? 1402 00:56:20,643 --> 00:56:22,746 >> I DON'T KNOW IF I AM THE 1403 00:56:22,812 --> 00:56:24,948 ONLY PERSON DOING THIS. 1404 00:56:25,014 --> 00:56:26,116 THERE'S DEFINITELY OTHERS WHO 1405 00:56:26,182 --> 00:56:28,752 ARE WORKING IN THIS SPACE AND 1406 00:56:28,818 --> 00:56:31,087 DOING THIS BUT, YOU KNOW, I 1407 00:56:31,154 --> 00:56:32,922 DEFINITELY THINK THERE'S FEWER 1408 00:56:32,989 --> 00:56:36,493 OF US THINKING ABOUT THIS THAN 1409 00:56:36,559 --> 00:56:39,028 THERE COULD BE AND, YEAH, I 1410 00:56:39,095 --> 00:56:40,797 THINK YOU KNOW THE STRONGER 1411 00:56:40,864 --> 00:56:42,599 OUR DATA IS, THE STRONGER 1412 00:56:42,665 --> 00:56:46,136 ARGUMENT WE CAN MAKE TO MAKE 1413 00:56:46,202 --> 00:56:50,306 STRUCTURAL AND POLICY AND 1414 00:56:50,373 --> 00:56:51,608 INTERVENTIONAL CHANGES AND GET 1415 00:56:51,674 --> 00:56:53,343 RESOURCES TO SOLVE SOME OF 1416 00:56:53,409 --> 00:56:55,645 THESE PROBLEMS AND HOPEFULLY 1417 00:56:55,712 --> 00:56:56,546 IMPROVE HEALTH EQUITY. 1418 00:56:56,613 --> 00:56:58,014 SO I THINK THE STRENGTH OF OUR 1419 00:56:58,081 --> 00:56:59,716 DATA I THINK HAS A REALLY 1420 00:56:59,783 --> 00:57:04,220 DIRECT TIE TO THE RESOURCES 1421 00:57:04,287 --> 00:57:07,223 THAT EVENTUALLY ARE PUT WITH 1422 00:57:07,290 --> 00:57:07,657 RISK. 1423 00:57:07,724 --> 00:57:08,858 >> ANY INNOVATIVE RESEARCH AND 1424 00:57:08,925 --> 00:57:13,263 NEW THINGS IN THE FIELD, 1425 00:57:13,329 --> 00:57:13,930 EXPECTING CHALLENGES? 1426 00:57:13,997 --> 00:57:15,698 >> YEAH, I THINK THE FIRST 1427 00:57:15,765 --> 00:57:18,401 THING, YOU KNOW, IS GETTING 1428 00:57:18,468 --> 00:57:21,371 SOME OF THESE METHODS OUT 1429 00:57:21,437 --> 00:57:21,805 THERE. 1430 00:57:21,871 --> 00:57:23,673 YOU KNOW, TO THE PEOPLE USING 1431 00:57:23,740 --> 00:57:27,343 THEM OR WHO SHOULD BE USING 1432 00:57:27,410 --> 00:57:30,280 THEM, I THINK IS A GAP NOT 1433 00:57:30,346 --> 00:57:34,851 JUST FOR HEALTH DISPARITIES 1434 00:57:34,918 --> 00:57:37,487 BUT LIKE THE PAPER THAT I WAS 1435 00:57:37,554 --> 00:57:43,092 DEFENDING ON IS A PRIMER IN 1436 00:57:43,159 --> 00:57:45,595 THIS FOR RESEARCH BEING DONE 1437 00:57:45,662 --> 00:57:48,665 ALL OVER THE PLACE ON CANCER 1438 00:57:48,731 --> 00:57:50,533 TREATMENTS ON OUTCOME AND SOME 1439 00:57:50,600 --> 00:57:52,936 OF THEM ARE NOT DESIGNING 1440 00:57:53,002 --> 00:57:56,506 THEIR STUDIES CORRECTLY AND 1441 00:57:56,573 --> 00:57:58,775 THEN PUBLISHING THE RESULTS 1442 00:57:58,842 --> 00:58:01,611 AND THE IMMORTAL TIME BIAS 1443 00:58:01,678 --> 00:58:04,848 DOESN'T GET PICKED UP BY THE 1444 00:58:04,914 --> 00:58:06,783 RESEARCHERS BECAUSE THEY DON'T 1445 00:58:06,850 --> 00:58:10,887 GET TRAINING ON IMMORTAL BIAS. 1446 00:58:10,954 --> 00:58:14,357 SO WE DIDN'T CREATE THIS 1447 00:58:14,424 --> 00:58:16,092 METHOD, SOME OF MY 1448 00:58:16,159 --> 00:58:18,962 CORESEARCHERS ARE MORE VERSED 1449 00:58:19,028 --> 00:58:20,530 IN THIS METHOD THAN I AM BUT 1450 00:58:20,597 --> 00:58:22,532 TO LOOK AT THE STRATEGIES OF 1451 00:58:22,599 --> 00:58:23,666 THE DIFFERENT PAPERS, THERE 1452 00:58:23,733 --> 00:58:26,836 HAS TO BE AN ACCEPTANCE TO 1453 00:58:26,903 --> 00:58:27,670 GETTING THIS PUBLISHED. 1454 00:58:27,737 --> 00:58:38,281 WE HAVE HAD A LITTLE TROUBLE 1455 00:58:38,548 --> 00:58:40,283 FINDING A JOURNAL THAT WOULD 1456 00:58:40,350 --> 00:58:41,217 BE APPROPRIATE FOR THIS. 1457 00:58:41,284 --> 00:58:44,320 AND I THINK THE SAME COULD BE 1458 00:58:44,387 --> 00:58:47,390 SAID FOR HEALTH DISPARITY 1459 00:58:47,457 --> 00:58:48,324 RESEARCHERS, USING THE 1460 00:58:48,391 --> 00:58:50,293 TRAINING TO FOCUS ON A 1461 00:58:50,360 --> 00:58:52,295 SPECIFIC TYPE OF METHOD 1462 00:58:52,362 --> 00:58:53,863 LOGICAL TRAINING, SOCIAL, HOW 1463 00:58:53,930 --> 00:58:56,733 TO MENTOR THESE CONCEPTS AND 1464 00:58:56,799 --> 00:58:59,669 HOW TO DESIGN THESE KINDS OF 1465 00:58:59,736 --> 00:59:03,206 STUDIES BUT THEN IT MIGHT 1466 00:59:03,273 --> 00:59:04,474 POTENTIALLY FOCUS ON LESS OF 1467 00:59:04,540 --> 00:59:05,842 THESE AND SOME OF THEM DON'T 1468 00:59:05,909 --> 00:59:07,944 HAVE A DIRECT TIE TO WHAT 1469 00:59:08,011 --> 00:59:11,347 WE'RE DOING BUT DOESN'T MEAN 1470 00:59:11,414 --> 00:59:13,182 THAT WE CAN'T USE THEM. 1471 00:59:13,249 --> 00:59:14,684 SO THE ACCESS IS IMPORTANT AND 1472 00:59:14,751 --> 00:59:16,552 WHEN YOU ARE DOING HOPEFULLY 1473 00:59:16,619 --> 00:59:18,154 SOMETHING LIKE THIS AND BEING 1474 00:59:18,221 --> 00:59:20,523 OPEN TO LISTENING TO MORE 1475 00:59:20,590 --> 00:59:23,226 METHODS AND ALSO HAVING IT BE 1476 00:59:23,293 --> 00:59:25,561 MORE ACCESSIBLE, I THINK, WILL 1477 00:59:25,628 --> 00:59:30,166 ONLY HELP TO INCLUDE THAT. 1478 00:59:30,233 --> 00:59:30,633 >> ABSOLUTELY. 1479 00:59:30,700 --> 00:59:32,535 AND I HAVE LEARNED A LOT FROM 1480 00:59:32,602 --> 00:59:39,642 THIS AND I AM AN 1481 00:59:39,709 --> 00:59:40,910 EPIDEMIOLOGIST AND I AM 1482 00:59:40,977 --> 00:59:42,111 LOOKING FORWARD TO LEARNING 1483 00:59:42,178 --> 00:59:47,150 MORE ABOUT THIS METHOD AND 1484 00:59:47,216 --> 00:59:47,850 COLLABORATING HOPEFULLY ON 1485 00:59:47,917 --> 00:59:49,152 SOME OF THESE PROJECTS WITH 1486 00:59:49,218 --> 00:59:49,819 YOU. 1487 00:59:49,886 --> 00:59:52,288 >> YEAH, I WOULD BE HAPPY TO. 1488 00:59:52,355 --> 00:59:56,693 >> WELL THANK YOU, 1489 00:59:56,759 --> 00:59:57,293 PAULA STRASSLE FOR YOUR 1490 00:59:57,360 --> 00:59:58,061 PRESENTATION AND I WILL STAY 1491 00:59:58,127 --> 00:59:59,228 TUNED FOR THAT PUBLICATION. 1492 00:59:59,295 --> 01:00:00,430 >> THANK YOU SO MUCH AND THANK 1493 01:00:00,496 --> 01:00:07,503 YOU FOR HAVING ME. . 1494 01:00:07,570 >> TAKE CARE.