Opinion
VIEWPOINT
Time Until Treatment Equipoise
A New Concept in Surgical Decision Making
Alia Noorani, MRCS When operations are performed purely on prognos-
Department of tic grounds, the decision to operate is based on
Cardiothoracic Surgery, weighing the risk of the intervention against that of no
Papworth Hospital,
intervention (conservative treatment). Because the
Cambridge, England.
risk of the former is usually immediate and that of the
Mikko Hippelainen, MD latter is spread out, the time over which the risk is
Department of measured becomes important, and this is heavily
Cardiothoracic Surgery, dependent on the patient’s age. There is no accepted
Kuopio University
method of comparing risk between conservative and
Hospital, Kuopio,
Finland. invasive therapies. Furthermore, there is no agreed
standard that relates the magnitude of risk to the pas-
Samer A. M. Nashef, sage of time. We therefore propose a new approach
FRCS to help in decision making for both physicians
Department of
Cardiothoracic Surgery,
and patients contemplating invasive interventions for
Papworth Hospital, purely prognostic indications. This approach is
Cambridge, England. not proposed for operations carried out to relieve
symptoms.
Time Until Treatment Equipoise
We postulate a concept of “time until treatment equi-
poise” (TUTE) to advise patients of relative risks of the
2 approaches. We define this as the duration of time
that elapses after an intervention, before the risk
of the intervention is nullified and reversed by the
cumulative risk of conservative management. It is
expressed as a single figure (hours to years) and is
simple to understand and to explain to patients.
Usage may guide decision making when surgery is
contemplated for asymptomatic patients purely on
prognostic grounds.
Development
The concept of TUTE has been defined and developed
using certain clinical conditions as examples. Consider
a hypothetical condition where the risk of surgery is
10% and that of medical management is 5% per year
(Figure, A). When equipoise occurs is debatable. Two
points are contenders for this: the crossover point of
the survival curve and the point at which the areas
under the curves are equal. We have chosen the latter
for 2 reasons. First, patients make their decision
poised at the beginning of the graph. Reaching equi-
poise at the crossover point is insufficient to justify
surgery if the survival lines do not diverge afterward.
Indeed, if the purpose is simply to reach the crossover
point, then arriving there with medical treatment is
preferable to surgery, with its attendant morbidity.
Corresponding
What happens after the crossover point is vitally
Author: Samer A. M. important: the wider the divergence of the survival
Nashef, FRCS, lines, the more convincing the evidence for surgery.
Papworth Hospital,
Second, although the probability of survival is equal at
Cambridge CB23 3RE,
England (sam.nashef the crossover point, the areas between the lines are
@papworth.nhs.uk). the difference of lost life-years between the groups.
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When the area between the curves on either side of
the crossover point is equal, the number of lost life-
years is also equal in both groups. In simple graphical
terms, TUTE is therefore defined as the point at which
the area between the 2 survival lines equalizes. Here,
the excess risk taken by accepting an intervention is
reversed by the same amount of risk taken by con-
tinuing with medical treatment after the survival lines
cross.
We further explain this concept using 4 distinct
clinical conditions as examples. In a 60-year-old
patient with asymptomatic tight left main stem
coronary artery stenosis and no additional risk
factors, TUTE for coronary artery bypass surgery is 2
months (Figure, B). For acute type A aortic dissection,
TUTE is 46 hours (Figure, C); for replacement of the
ascending aorta for a 6-cm aneurysm, 38 months
(Figure, D); and for anatomic repair of congenitally
corrected transposition of the great arteries, 55 years
(Figure, E).1-4
A preliminary search has identified that there are
data to allow calculation of TUTE for many conditions,
including cancer, for which prognostic surgery is cur-
rently undertaken. It is important to realize that the
concept refers to a risk to life from a procedure and
does not account for morbidity associated with either
approach.
Discussion
Operations performed to treat symptoms are rela-
tively easy to explain to patients when obtaining con-
sent. For example, a patient troubled by angina may
be prepared to accept an operation with a risk of 1%
to life to be free of angina. As the risk of surgery and
other interventions reduces, they can be justified on
purely prognostic grounds in asymptomatic patients.
The patient has then to compare the risk of the inter-
vention against that of conservative treatment to
decide whether to proceed with intervention. At first
glance, this may not appear to pose a problem but in
practice is a very difficult comparison to make. This is
primarily because the risk of intervention is generally
concentrated at the time of the procedure and imme-
diately afterward, whereas the risk of conservative
treatment is spread over a longer period. One could
argue that the risk of the intervention should be com-
pared against an arbitrarily chosen period of conserva-
tive treatment, for example, 2 years. However, this
approach does not work for all ages of patients. A
75-year-old may be prepared to accept equivalence
between a 5% risk of an operation against a 5% mor-
tality risk of conservative treatment over 2 years, but
a 92-year-old will not consider it worthwhile, whereas
JAMA Surgery February 2014 Volume 149, Number 2 109
 Opinion Viewpoint

Figure. Concept Illustration

A
TUTE
100

Surgery
80
Survival, %

60
Medicine

40

20

0
0 1 2 3 4 5 6 7 8 9 10
Years

B C
TUTE TUTE
100 100
Surgery

80 80
Surgery
Survival, %

60 Survival, % 60

Medicine
40 40
Medicine

20 20

0 0
0 12 24 36 0 7 365 3650
Months Days

D E
TUTE TUTE
100 100

Surgery Surgery
80 80
Survival, %

Survival, %

60 60
Medicine
Medicine
40 40

20 20

0 0
0 1 2 3 4 0 5 10 15 20 25 30 35 40 45 50 55 60
Years Years

A, Survival vs time for a hypothetical condition with 10% surgical and 5% is 46 hours. D, TUTE for a 6-cm ascending aortic aneurysm is 38 months.
annual mortality for conservative management. Time until treatment equipoise E, TUTE for anatomic repair of congenitally corrected transposition of the great
(TUTE) occurs at 56 months. B, TUTE for asymptomatic tight left main stem arteries is 55 years.
coronary artery stenosis is 2 months. C, TUTE for acute type A aortic dissection

a 20-year-old who opts for conservative treatment under such
circumstances will have accumulated a 50% risk of death before
age 40 years. That such decisions are age dependent is self-
evident, but it is difficult to find a simple method that can be con-
sistently applicable to all ages and in which the risks of both
approaches can be sensibly and easily compared. This is why we
propose TUTE as a useful concept.
Our chosen examples are neither exhaustive in their selection
nor in the data cited to support them. They are merely used to
illustrate the concept. If TUTE finds wider acceptance, more thor-
ough literature review will be needed to define the precise TUTE
in these and other conditions. Time until treatment equipoise is
necessarily limited by available information on natural disease
progression.

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 Viewpoint Opinion

Conclusions purely for prognosis. It may help guide decision making and
Time until treatment equipoise is a simple concept, applicable informed consent whenever prognostic invasive intervention is
to many conditions where intervention is contemplated considered.

ARTICLE INFORMATION
Published Online: December 4, 2013.
doi:10.1001/jamasurg.2013.3066.
Conflict of Interest Disclosures: None reported.
REFERENCES
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2. Conley MJ, Ely RL, Kisslo J, Lee KL, McNeer JF,
Rosati RA. The prognostic spectrum of left main
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3. Elefteriades JA. Natural history of thoracic aortic
aneurysms: indications for surgery, and surgical
versus nonsurgical risks. Ann Thorac Surg.
2002;74(5):S1877-S1880, discussion S1892-S1898.
4. Murtuza B, Barron DJ, Stumper O, et al.
Anatomic repair for congenitally corrected
transposition of the great arteries:
a single-institution 19-year experience. J Thorac
Cardiovasc Surg. 2011;142(6):1348-1357, e1.

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