title: When to perform hepatic resection for intermediate-stage hepatocellular carcinoma.
abstract: 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 (Pt) 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 Pt 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 Pt 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.
  
  
  CONCLUSIONS
  Regret theory provides a new perspective for treatment-related decisions applicable to the setting of intermediate HCC.
authors.affiliation: Department of Medical and Surgical Sciences, S. Orsola-Malpighi Hospital, Alma Mater Studiorum-University of Bologna, Bologna, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Cucchetti
authors.forename: Benjamin
authors.initials: B
authors.lastname: Djulbegovic
authors.forename: Athanasios
authors.initials: A
authors.lastname: Tsalatsanis
authors.forename: Alessandro
authors.initials: A
authors.lastname: Vitale
authors.forename: Iztok
authors.initials: I
authors.lastname: Hozo
authors.forename: Fabio
authors.initials: F
authors.lastname: Piscaglia
authors.forename: Matteo
authors.initials: M
authors.lastname: Cescon
authors.forename: Giorgio
authors.initials: G
authors.lastname: Ercolani
authors.forename: Francesco
authors.initials: F
authors.lastname: Tuci
authors.forename: Umberto
authors.initials: U
authors.lastname: Cillo
authors.forename: Antonio Daniele
authors.initials: AD
authors.lastname: Pinna
mesh_terms: D000368:Aged; D006528:Carcinoma, Hepatocellular / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D016461:Chemoembolization, Therapeutic; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008113:Liver Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D008297:Male; D008875:Middle Aged; D009367:Neoplasm Staging; D016016:Proportional Hazards Models; D013997:Time Factors