# Adjusting for switches to multiple treatments: Should switches be handled separately or combined?

## TL;DR

This study compares methods to adjust for treatment switching in clinical trials, finding no significant difference between handling switches separately or combined.

## Contribution

The paper introduces a novel comparison of statistical methods for handling multiple treatment switches in RCTs.

## Key findings

- Both 'treatments combined' and 'treatments separate' approaches produced similar levels of bias in survival time estimates.
- There was no significant advantage to adjusting for each switch type separately over combining them.

## Abstract

Treatment switching is common in randomised controlled trials (RCTs). Participants may switch onto a variety of different treatments, all of which may have different treatment effects. Adjustment analyses that target hypothetical estimands – estimating outcomes that would have been observed in the absence of treatment switching – have focused primarily on a single type of switch. In this study, we assess the performance of applications of inverse probability of censoring weights (IPCW) and two-stage estimation (TSE) which adjust for multiple switches by either (i) adjusting for each type of switching separately (‘treatments separate’) or (ii) adjusting for switches combined without differentiating between switched-to treatments (‘treatments combined’). We simulate 48 scenarios in which RCT participants may switch to multiple treatments. Switch proportions, treatment effects, number of switched-to treatments and censoring proportions were varied. Method performance measures included mean percentage bias in restricted mean survival time and the frequency of model convergence. Similar levels of bias were produced by treatments combined and treatments separate in both TSE and IPCW applications. In the scenarios examined, there was no demonstrable advantage associated with adjusting for each type of switch separately, compared with adjusting for all switches together.