title: Decision trees for identifying predictors of treatment effectiveness in clinical trials and its application to ovulation in a study of women with polycystic ovary syndrome.
abstract: BACKGROUND
  Double-blind, randomized clinical trials are the preferred approach to demonstrating the effectiveness of one treatment against another. The comparison is, however, made on the average group effects. While patients and clinicians have always struggled to understand why patients respond differently to the same treatment, and while much hope has been held for the nascent field of predictive biomarkers (e.g. genetic markers), there is still much utility in exploring whether it is possible to estimate treatment efficacy based on demographic and baseline variables.
  
  
  METHODS
  The pregnancy in polycystic ovary syndrome (PPCOS) study was a prospective, multi-center, randomized clinical trial comparing three ovulation induction regimens: clomiphene citrate (CC), metformin and the combination of the two. There were 446 women who ovulated in response to the treatments among the entire 626 participants. In this report, we focus on the 418 women who received CC (alone or combined with metformin) to determine if readily available baseline physical characteristics and/or easily obtainable baseline measures could be used to distinguish treatment effectiveness in stimulating ovulation. We used a recursive partitioning technique and developed a node-splitting rule to build decision tree models that reflected within-node and within-treatment responses.
  
  
  RESULTS
  Overall, the combination of CC plus metformin resulted in an increased incidence of ovulation compared with CC alone. This is particularly so in women with relatively larger left ovarian volumes (≥ 19.5 cubic cm), and a left ovarian volume <19.5 cubic cm was related to treatment outcomes for all subsequent nodes. Women who were older, who had higher baseline insulin, higher waist-to-hip circumference ratio or higher sex hormone-binding globulin levels had better ovulatory rates with CC alone than with the combination of CC plus metformin.
  
  
  CONCLUSIONS
  Polycystic ovary syndrome (PCOS) is a phenotypically diverse condition. Both baseline laboratory and clinical parameters can predict the ovulatory response in women with PCOS undergoing ovulation induction. Without a priori hypotheses with regard to any predictors, the observation regarding left ovary volume is novel and worthy of further investigation and validation.
authors: Department of Epidemiology and Public Health, Yale University School of Medicine, New Haven, CT 06520-8034, USA. heping.zhang@yale.edu
authors: Heping
authors: H
authors: Zhang
authors: Richard S
authors: RS
authors: Legro
authors: Jeffrey
authors: J
authors: Zhang
authors: Leon
authors: L
authors: Zhang
authors: Xiang
authors: X
authors: Chen
authors: Hao
authors: H
authors: Huang
authors: Peter R
authors: PR
authors: Casson
authors: William D
authors: WD
authors: Schlaff
authors: Michael P
authors: MP
authors: Diamond
authors: Stephen A
authors: SA
authors: Krawetz
authors: Christos
authors: C
authors: Coutifaris
authors: Robert G
authors: RG
authors: Brzyski
authors: Gregory M
authors: GM
authors: Christman
authors: Nanette
authors: N
authors: Santoro
authors: Esther
authors: E
authors: Eisenberg
mesh_terms: D000367:Age Factors; D000728:Androgens / Q000097:blood; D000858:Anovulation / Q000188:drug therapy; D015992:Body Mass Index; D002996:Clomiphene / Q000627:therapeutic use; D003663:Decision Trees; D004359:Drug Therapy, Combination; D005260:Female; D005300:Fertility Agents, Female / Q000627:therapeutic use; D006801:Humans; D007247:Infertility, Female / Q000188:drug therapy*; D008687:Metformin / Q000627:therapeutic use; D009929:Organ Size; D010062:Ovulation Induction; D011085:Polycystic Ovary Syndrome / Q000188:drug therapy*; D011247:Pregnancy; D011384:Proinsulin / Q000097:blood; D016032:Randomized Controlled Trials as Topic; D012738:Sex Hormone-Binding Globulin / Q000032:analysis; D016896:Treatment Outcome; D049629:Waist-Hip Ratio
chemical_list: D000728:Androgens; D005300:Fertility Agents, Female; D012738:Sex Hormone-Binding Globulin; D002996:Clomiphene; D011384:Proinsulin; D008687:Metformin