On the limitations of causal inference with current-treatment Cox models
Cox models with time-varying treatments often include only the current treatment level. Translating such a model into causally meaningful intervention-specific survival probabilities relies on the Markov property: that the hazard is independent of treatment history conditional on current treatment. For the Markov property to not be population-specific, it needs to hold also conditional on any unmeasured prognostic heterogeneity (frailty). Using a discrete-time argument, earlier work concluded that the Markov property can hold both conditionally and marginally only in the absence of a treatment effect or an effect of the unmeasured heterogeneity. We broaden this argument by developing a continuous-time framework that encompasses both proposed extensions of the Kaplan-Meier curve and current-treatment marginal structural Cox models, and sharpen it by characterizing precisely the conditions under which the Markov property can hold both conditionally and marginally. Specifically, we show that it requires the absence of treatment-frailty interaction on the additive hazard scale. As frailty is inherently unmeasured, such a no-interaction assumption cannot be verified. Consequently, causal interpretation of a current-treatment marginal structural Cox model rests on a strong and unverifiable structural assumption. Illustrating this point, we construct a setting in which a Cox model is correctly specified conditionally on current treatment only, although the marginal Markov property fails. Transforming the fitted model to the survival scale does not recover the true intervention-specific survival probabilities. Thus, moving from the hazard scale to the survival scale is not in itself sufficient to obtain a causal interpretation in the time-varying treatment setting.