title: Defining optimum treatment of patients with pancreatic adenocarcinoma using regret-based decision curve analysis.
abstract: OBJECTIVE
  To use regret decision theory methodology to assess three treatment strategies in pancreatic adenocarcinoma.
  
  
  BACKGROUND
  Pancreatic adenocarcinoma is uniformly fatal without operative intervention. Resection can prolong survival in some patients; however, it is associated with significant morbidity and mortality. Regret theory serves as a novel framework linking both rationality and intuition to determine the optimal course for physicians facing difficult decisions related to treatment.
  
  
  METHODS
  We used the Cox proportional hazards model to predict survival of patients with pancreatic adenocarcinoma and generated a decision model using regret-based decision curve analysis, which integrates both the patient's prognosis and the physician's preferences expressed in terms of regret associated with a certain action. A physician's treatment preferences are indicated by a threshold probability, which is the probability of death/survival at which the physician is uncertain whether or not to perform surgery. The analysis modeled 3 possible choices: perform surgery on all patients; never perform surgery; and act according to the prediction model.
  
  
  RESULTS
  The records of 156 consecutive patients with pancreatic adenocarcinoma were retrospectively evaluated by a single surgeon at a tertiary referral center. Significant independent predictors of overall survival included preoperative stage [P = 0.005; 95% confidence interval (CI), 1.19-2.27], vitality (P < 0.001; 95% CI, 0.96-0.98), daily physical function (P < 0.001; 95% CI, 0.97-0.99), and pathological stage (P < 0.001; 95% CI, 3.06-16.05). Compared with the "always aggressive" or "always passive" surgical treatment strategies, the survival model was associated with the least amount of regret for a wide range of threshold probabilities.
  
  
  CONCLUSIONS
  Regret-based decision curve analysis provides a novel perspective for making treatment-related decisions by incorporating the decision maker's preferences expressed as his or her estimates of benefits and harms associated with the treatment considered.
authors.affiliation: *Department of Surgery, Division of General Surgery, University of South Florida, Tampa, FL †Center for Evidence-Based Medicine, University of South Florida, Tampa, FL ‡Department of Internal Medicine, Division of Evidence-Based Medicine, Tampa, FL §Department of Hematology and Health Outcomes and Behavior, H. Lee Moffitt Cancer Center & Research Institute, Tampa, FL.
authors.forename: Jonathan M
authors.initials: JM
authors.lastname: Hernandez
authors.forename: Athanasios
authors.initials: A
authors.lastname: Tsalatsanis
authors.forename: Leigh Ann
authors.initials: LA
authors.lastname: Humphries
authors.forename: Branko
authors.initials: B
authors.lastname: Miladinovic
authors.forename: Benjamin
authors.initials: B
authors.lastname: Djulbegovic
authors.forename: Vic
authors.initials: V
authors.lastname: Velanovich
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D000368:Aged; D003131:Combined Modality Therapy / Q000592:standards; D003657:Decision Making; D003661:Decision Support Techniques; D005260:Female; D005431:Florida / Q000453:epidemiology; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D009367:Neoplasm Staging / Q000379:methods*; D010190:Pancreatic Neoplasms / Q000175:diagnosis / Q000401:mortality / Q000628:therapy*; D010819:Physician's Role; D011336:Probability; D011379:Prognosis; D016016:Proportional Hazards Models; D012189:Retrospective Studies