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Decision-Making for Preventive Interventions in Asymptomatic Patients
Abstract
The
decision to treat an incidental finding in an asymptomatic patient
results from careful risk-benefit consideration and is often
challenging. One of the main aspects is after how many years the group
who underwent the intervention and faced the immediate treatment
complications will gain a treatment benefit over the conservatively
managed group, which maintains a lower but ongoing risk. We identify a
common error in decision-making. We illustrate how a risk-based approach
using the classical break-even point at the Kaplan-Meier curves can be
misleading and advocate for using an outcome-based approach, counting
the cumulative number of lost quality-adjusted life years instead. In
clinical practice, we often add together the yearly risk of the natural
course up to the time point where the number equals the risk of the
intervention and assume that the patient will benefit from an
intervention beyond this point in time. It corresponds to the crossing
of the Kaplan-Meier curves. However, because treatment-related poor
outcome occurs at the time of the intervention, while the poor outcome
in the conservative group occurs over a given time period, the true
benefit of retaining more quality-adjusted life years in the
interventional group emerges at a much later time. To avoid
overtreatment of patients with asymptomatic diseases, decision-making
should be outcome-based with counting the cumulative loss of
quality-adjusted life years, rather than risk-based, comparing the
interventional risk with the ongoing yearly risk of the natural course.
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