title: Defining when to offer operative treatment for intrahepatic cholangiocarcinoma: A regret-based decision curves analysis.
abstract: Regret-based decision curve analysis (DCA) is a framework that assesses the medical decision process according to physician attitudes (expected regret) relative to disease-based factors. We sought to apply this methodology to decisions around the operative management of intrahepatic cholangiocarcinoma (ICC).
  
  
  
  Utilizing a multicentric database of 799 patients who underwent liver resection for ICC, we developed a prognostic nomogram. DCA tested 3 strategies: (1) perform an operation on all patients, (2) never perform an operation, and (3) use the nomogram to select patients for an operation.
  
  
  
  Four preoperative variables were included in the nomogram: major vascular invasion (HR = 1.36), tumor number (multifocal, HR = 1.18), tumor size (>5 cm, HR = 1.45), and suspicious lymph nodes on imaging (HR = 1.47; all P < .05). The regret-DCA was assessed using an online survey of 50 physicians, expert in the treatment of ICC. For a patient with a multifocal ICC, largest lesion measuring >5 cm, one suspicious malignant lymph node, and vascular invasion on imaging, the 1-year predicted survival was 52% according to the nomogram. Based on the therapeutic decision of the regret-DCA, 60% of physicians would advise against an operation for this scenario. Conversely, all physicians recommended an operation to a patient with an early ICC (single nodule measuring 3 cm, no suspicious lymph nodes, and no vascular invasion at imaging).
  
  
  
  By integrating a nomogram based on preoperative variables and a regret-based DCA, we were able to define the elements of how decisions rely on medical knowledge (postoperative survival predicted by a nomogram, severity disease assessment) and physician attitudes (regret of commission and omission).
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Fabio
authors.initials: F
authors.lastname: Bagante
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Gaya
authors.initials: G
authors.lastname: Spolverato
authors.affiliation: University of Bologna, Ospedale S. Orsola-Malpighi, Bologna, Italy.
authors.forename: Alessandro
authors.initials: A
authors.lastname: Cucchetti
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD.
authors.forename: Faiz
authors.initials: F
authors.lastname: Gani
authors.affiliation: Fundeni Clinical Institute, Bucharest, Romania.
authors.forename: Irinel
authors.initials: I
authors.lastname: Popescu
authors.affiliation: University of Verona, Policlinico GB Rossi, Verona, Italy.
authors.forename: Andrea
authors.initials: A
authors.lastname: Ruzzenente
authors.affiliation: Curry Cabral Hospital, Lisbon, Portugal.
authors.forename: Hugo P
authors.initials: HP
authors.lastname: Marques
authors.affiliation: Ospedale San Raffaele, Milan, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Aldrighetti
authors.affiliation: Medical College of Wisconsin, Milwaukee, WI.
authors.forename: T Clark
authors.initials: TC
authors.lastname: Gamblin
authors.affiliation: Emory University, Atlanta, GA.
authors.forename: Shishir K
authors.initials: SK
authors.lastname: Maithel
authors.affiliation: University of Sydney, Sydney, Australia.
authors.forename: Charbel
authors.initials: C
authors.lastname: Sandroussi
authors.affiliation: University of Virginia, Charlottesville, VA.
authors.forename: Todd W
authors.initials: TW
authors.lastname: Bauer
authors.affiliation: Eastern Hepatobiliary Surgery Hospital, Shanghai, China.
authors.forename: Feng
authors.initials: F
authors.lastname: Shen
authors.affiliation: Stanford University, Stanford, CA.
authors.forename: George A
authors.initials: GA
authors.lastname: Poultsides
authors.affiliation: University of Pittsburgh Medical Center, Pittsburgh, PA.
authors.forename: James Wallis
authors.initials: JW
authors.lastname: Marsh
authors.affiliation: University of Verona, Policlinico GB Rossi, Verona, Italy.
authors.forename: Alfredo
authors.initials: A
authors.lastname: Guglielmi
authors.affiliation: Johns Hopkins University School of Medicine, Baltimore, MD. Electronic address: tpawlik1@jhmi.edu.
authors.forename: Timothy M
authors.initials: TM
authors.lastname: Pawlik
mesh_terms: D000368:Aged; D001291:Attitude of Health Personnel; D001650:Bile Duct Neoplasms / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D001653:Bile Ducts, Intrahepatic; D018281:Cholangiocarcinoma / Q000401:mortality / Q000473:pathology / Q000601:surgery*; D000066491:Clinical Decision-Making; D003661:Decision Support Techniques; D004644:Emotions; D005260:Female; D006498:Hepatectomy; D006801:Humans; D008297:Male; D008875:Middle Aged; D049451:Nomograms; D015996:Survival Rate