Adjusting for Heavy Censoring and Double-Dipping to Compare Risk Stratification Abilities of Existing Models for Time to Diagnosis of Huntington Disease

Huntington disease (HD) is a genetically inherited neurodegenerative disease with progressively worsening symptoms. Accurately modeling time to HD diagnosis is essential for clinical trial design and treatment planning. Langbehn's model, the CAG-Age Product (CAP) model, the Prognostic Index Normed (PIN) model, and the Multivariate Risk Score (MRS) model have all been proposed for this task. However, differing in methodology, assumptions, and accuracy, these models may yield conflicting predictions. Few studies have systematically compared these models' performance, and those that have could be misleading due to (i) testing the models on the same data used to train them and (ii) failing to account for high rates of right censoring (80%+) in performance metrics. We discuss the theoretical foundations of the four most common models of time to HD diagnosis, offering intuitive comparisons about their practical feasibility. Further, we externally validate their risk stratification abilities using data from the ENROLL-HD study and performance metrics that adjust for censoring. Our findings guide the selection of a model for HD clinical trial design. The MRS model, which incorporates the most covariates, performed the best. However, the simpler CAP and PIN models were not far behind and may be logistically simpler to adopt. We also show how these models can be used to estimate sample sizes for an HD clinical trial, emphasizing that previous estimates would lead to underpowered trials.