LETTER TO THE EDITOR Considerations in the Early Termination of Clinical Trials in Surgery To the Editor: E thics and statistics collide in decisions re- lating to the early termination of clinical trials. Investigators have a fundamental re- sponsibility to stop a trial where an excess of harm is seen in one of the arms. Decisions on stopping are not straightforward and must bal- ance the potential risk to trial patients against the likelihood that in fact there is no differ- ence in outcome between groups. Indeed, in early termination, the potential loss of gen- eralizable knowledge may itself harm future patients. We therefore read with interest the article by Van Buren and colleagues 1 and congratulate the authors on the first multi- center randomized trial on the controversial topic of surgical drains after pancreaticoduo- denectomy. As the authors report, the trial was stopped by the Data Safety Monitoring Board after only 18% recruitment due to a numerical excess of deaths in the “no-drain” arm. We would be interested in learning from the process that led to the decision to terminate the trial. A common method to monitor adverse events advocated by the CONSORT group is to define formal sequen- tial stopping rules based on the limit of ac- ceptable adverse event rates. 2 These guide- lines suggest that authors report the number of planned “looks” at the data, the statistical methods used including any formal stopping rules, and whether these were planned before trial commencement. This information is often not included in published trial reports, even when early termination has occurred. 3 We feel that in the context of important surgical trials, these guidelines should be adhered to. Disclosure: The authors declare no conflicts of interest. Copyright C  2014 by Lippincott Williams & Wilkins ISSN: 0003-4932/14/00000-0001 DOI: 10.1097/SLA.0000000000001000 Early termination can reduce the sta- tistical power of a trial. This can be addressed by examining results as data accumulate, preferably by an independent data monitoring committee. However, performing multiple statistical examinations of accumulating data without appropriate correction can lead to erroneous results and interpretation. 4 For example, if accumulating data from a trial are examined at 5 interim analyses that use a P value of 0.05, the overall false-positive rate is nearer to 19% than to the nominal 5%. Several group sequential statistical methods are available to adjust for multiple analyses 5,6 and their use should be prespeci- fied in the trial protocol. Stopping rules may be formed by 2 broad methods, either using a Bayesian approach to evaluate the propor- tion of patients with adverse effects or us- ing a hypothesis testing approach with a se- quential probability ratio test to determine whether the acceptable adverse effects rate has been exceeded. Data are compared at each interim analysis and decisions based on pre- specified criteria. As an example, stopping rules for harm from a recent study used mod- ified Haybittle-Peto boundaries of 3 SDs in the first half of the study and 2 SDs in the second half. 7 The study of Van Buren and colleagues is reported to have been stopped after 18% recruitment due to an excess of 6 deaths in the “no-drain” arm. The relative risk of death at 90 days in the “no-drain” group versus the “drain” group was 3.94 (95% confidence in- terval, 0.87–17.90), equivalent to a difference of 1.78 SD. The primary outcome measure was any grade 2 complication or more and had a relative risk of 1.32 (5% confidence in- terval, 1.00–1.75), or 1.95 SD. The decision to terminate a trial early is not based on statistics alone. Judgments must be made using all the available evidence, in- cluding the biological and clinical plausibility of harm and the findings of previous studies. Statistical considerations should therefore be used as a starting point for decisions, rather than a definitive rule. The Data Safety Monitoring Board for the study of Van Buren and colleagues clearly felt that there was no option other than to terminate the trial. However, at least on statis- tical grounds, this occurred very early in the trial using conservative criteria. The question remains therefore is the totality of evidence convincing that the question posed has been unequivocally answered? We would suggest that this is not the case. In general terms, stopping a clinical trial early is a rare event that sends out a message that, because of the “sensational” effect, may have greater im- pact on the medical community than intended, making future studies in that area challenging. Tom K. Gallagher, MCh, FRCSI O. James Garden, FRCS Stephen J. Wigmore, MD, FRCS Ewen M. Harrison, PhD, FRCS Hepatobiliary and Transplant Surgery Royal Infirmary Edinburgh Edinburgh, England tomgallagher@rcsi.ie REFERENCES 1. Van Buren G, Bloomston M, Hughes SJ, et al. A randomised prospective multicenter trial of pancreaticoduodenectomy with and without rou- tine intraperitoneal drainage. Ann Surg. 2014;259: 605–612. 2. Moher D, Hopewell S, Schulz KF, et al. CONSORT 2010 explanation and elaboration: updated guide- lines for reporting parallel group randomised trial. BMJ. 2010;340:c869. 3. Montori VM, Devereaux PJ, Adhikari NK, et al. Randomized trials stopped early for benefit: a sys- tematic review. JAMA. 2005;294:2203–2209. 4. Geller NL, Pocock SJ. Interim analyses in random- ized clinical trials: ramifications and guidelines for practitioners. Biometrics. 1987;43:213–223. 5. Pocock SJ. When to stop a clinical trial. BMJ. 1992;305:235–240. 6. Berry DA. Interim analyses in clinical trials: classi- cal vs. Bayesian approaches. Stat Med. 1985;4:521– 526. 7. Connolly SJ, Pogue J, Hart RG, et al. Effect of clopidogrel added to aspirin in patients with atrial fibrillation. N Engl J Med. 2009;360:2066– 2078. Copyright © 2014 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. Annals of Surgery  Volume 00, Number 00, 2014 www.annalsofsurgery.com | 1