The Estimand Framework and Causal Inference: Complementary Not Competing Paradigms

The creation of the ICH E9 (R1) estimands framework has led to more precise specification of the treatment effects of interest in the design and statistical analysis of clinical trials. However, it is unclear how the new framework relates to causal inference, as both approaches appear to define what is being estimated and have a quantity labeled an estimand. Using illustrative examples, we show that both approaches can be used to define a population-based summary of an effect on an outcome for a specified population and highlight the similarities and differences between these approaches. We demonstrate that the ICH E9 (R1) estimand framework offers a descriptive, structured approach that is more accessible to non-mathematicians, facilitating clearer communication of trial objectives and results. We then contrast this with the causal inference framework, which provides a mathematically precise definition of an estimand and allows the explicit articulation of assumptions through tools such as causal graphs. Despite these differences, the two paradigms should be viewed as complementary rather than competing. The combined use of both approaches enhances the ability to communicate what is being estimated. We encourage those familiar with one framework to appreciate the concepts of the other to strengthen the robustness and clarity of clinical trial design, analysis, and interpretation.