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When to perform hepatic resection for intermediate‐stage hepatocellular carcinoma
Author(s) -
Cucchetti Alessandro,
Djulbegovic Benjamin,
Tsalatsanis Athanasios,
Vitale Alessandro,
Hozo Iztok,
Piscaglia Fabio,
Cescon Matteo,
Ercolani Giorgio,
Tuci Francesco,
Cillo Umberto,
Pinna Antonio Daniele
Publication year - 2015
Publication title -
hepatology
Language(s) - English
Resource type - Journals
SCImago Journal Rank - 5.488
H-Index - 361
eISSN - 1527-3350
pISSN - 0270-9139
DOI - 10.1002/hep.27321
Subject(s) - regret , hepatocellular carcinoma , medicine , cirrhosis , hepatectomy , stage (stratigraphy) , proportional hazards model , carcinoma , surgery , resection , gastroenterology , general surgery , paleontology , machine learning , computer science , biology
Transcatheter arterial chemoembolization (TACE) is the first‐line therapy recommended for patients with intermediate hepatocellular carcinoma (HCC). However, in clinical practice, these patients are often referred to surgical teams to be evaluated for hepatectomy. After making a treatment decision (e.g., TACE or surgery), physicians may discover that the alternative treatment would have been preferable, which may bring a sense of regret. Under this premise, it is postulated that the optimal decision will be the one associated with the least amount of regret. Regret‐based decision curve analysis (Regret‐DCA) was performed on a Cox's regression model developed on 247 patients with cirrhosis resected for intermediate HCC. Physician preferences on surgery versus TACE were elicited in terms of regret; threshold probabilities (P t ) were calculated to identify the probability of survival for which physicians are uncertain of whether or not to perform a surgery. A survey among surgeons and hepatologists regarding three hypothetical clinical cases of intermediate HCC was performed to assess treatment preference domains. The 3‐ and 5‐year overall survival rates after hepatectomy were 48.7% and 33.8%, respectively. Child‐Pugh score, tumor number, and esophageal varices were independent predictors of survival ( P < 0.05). Regret‐DCA showed that for physicians with P t values of 3‐year survival between 35% and 70%, the optimal strategy is to rely on the prediction model; for physicians with Pt <35%, surgery should be offered to all patients; and for P t values >70%, the least regretful strategy is to perform TACE on all patients. The survey showed a significant separation among physicians' preferences, indicating that surgeons and hepatologists can uniformly act according to the regret threshold model. Conclusion : Regret theory provides a new perspective for treatment‐related decisions applicable to the setting of intermediate HCC. (H epatology 2015;61:905–914)