Reply
Authors: Alessandro Cucchetti, Benjamin Djulbegovic
Journal: Hepatology (2015)

Potential conflict of interest: Nothing to report. We read with interest comments from Spacek and Solga regarding our work on regret‐based decision making for intermediate hepatocellular carcinoma (HCC). We thank them for the opportunity to further elucidate our approach. First, we described that clinicians "can be aggressive" recommending resection to all patients with intermediate HCCs. This statement should be viewed in light of international Eauropean Association for the Study of the Liver and American Association for the Study of Liver Diseases guidelines that recommend only transcatheter arterial chemoembolization in all patients with intermediate HCC.1 In this regard, surgery can be described as more aggressive and the nonparallel construction of the regret decision curve analysis (DCA) is forced by the avoidance of guidelines in recommending resection for intermediate HCC.1 Second, when stating that "…surgeons were more prone to experience the regret of omission," we refer to the observation (Table 5) that median values of regret of omission were significantly higher for the two clinical cases where surgery can be considered reasonably applicable (P < 0.05). Table 4 reports the results of clinical decision making according to regret DCA; thus, as stated in the article, we confirm that virtually all physicians can act according to the regret DCA model given that, as outlined by Spacek and Solga, this approach can lead to similar decisions regarding which treatment to adopt. The visual analog scale (VAS) has long been used in medicine for assessment of patients' emotions, such as distress, pain, and so on. When applying DVAS, we proposed to physicians a continuous range of values ranging from 0 (no regret) to 100 (maximum regret). We feel that there should be no reason to think that clinicians may have a different zero reference value, given that it was clearly explained in Fig. 1 that zero refers to the absence of regret. Finally, physicians involved in the survey had long expertise in the field of HCC. It is obvious that the final response of each of the 40 physicians involved was the end result of personal experience, feeling, intuition, as well as logical analysis and agreement with guidelines recommendations. This is what regret‐based DVAS was designed to asses: holistic evaluation of pros and cons of alternative strategies. In conducting the survey, we only sent the three clinical vignettes described in the Method section and the DVAS depicted in Fig. 1. We did not show the regret DCA model. Both vignettes and DVAS were related to the case, and not to the model itself. Thus, Spacek and Solga's observation regarding a possible influence by the attitude conveyed by our language in the article to the model is not supported. In addition, because holistic characteristics of regret DCA includes both emotional (as weighted through regret elicitation of DVAS survey) and analytical (as analyzed through Cox's regression model) aspects, we believe that type 1 and 2 cognitive aspects of decision making were fulfilled. In conclusion, current available surgical and nonsurgical literature suggests that, in clinical practice, there is a considerable disagreement regarding surgery for intermediate HCC,3 and that a multidisciplinary approach, and regret‐based approach, can help physicians select the most optimal treatment for each patient.