Comment on “when to perform hepatic resection for intermediate‐stage hepatocellular carcinoma”
Authors: Lisa A. Spacek, Steven F. Solga
Journal: Hepatology (2015)

Potential conflict of interest: Nothing to report. To the Editor: We applaud Cucchetti et al.1 for their thoughtful, thorough, and creative application of regret‐based decision curve analysis (DCA) for the treatment of intermediate‐stage hepatocellular carcinoma (HCC). We agree this approach offers a fresh and important perspective to a common clinical problem. We are concerned, however, that the authors may have introduced bias (description of the regret model). Regarding the clinical question, they state that a physician can be "aggressive" and recommend resection, or "withhold" surgery and administer transcatheter arterial chemoembolization (TACE) or "use the prediction model." Though this language accurately describes how the first two options are often conceptualized and practically discussed, this implies that a nonsurgical decision is nonaggressive or, worse, passive. This nonparallel construction is especially concerning for regret‐based DCA in cancer medicine. Memorials will often state that a patient succumbed only after a long "battle" or "valiant fight" with cancer, blurring the distinction between a medical illness and a moral campaign. Patients and their physicians do not want to be remembered as retreating from evil. Furthermore, we question the conclusion that the findings support that surgeons were more prone to experience the regret of omission and that "this is a feature fundamentally intrinsic to being a surgeon." According to survey results (Table 4), the predicted decisions of the majority of respondents are in agreement (115 of 120). Moreover, the differences observed when comparing the threshold probability (Pt) of surgeons versus hepatologists indicate that when results are discordant, surgeons prefer surgery (case 2, 3 of 40) and hepatologists prefer TACE (case 1, 2 of 40). Thus, a few participants who reported discordant results accounted for the reported difference. This may be a distinction without a difference. Likewise, in Table 5, we see a similar relative difference for surgeons (regret of omission, 90, 50, and 30) and hepatologists (regret of omission, 75, 30, and 20). It is unclear whether the values reported by participants responding to the dual visual analog scale have intrinsic value, as on a ratio scale where the zero point is fixed. It may be that the zero point is arbitrary, and the data represent an interval scale, for example, the zero point for Fahrenheit and Celsius temperature has a different meaning.2 Finally, no information is available about decision‐making influences, especially for the few discordant participants. Perhaps their decisions were driven by true differences in opinion regarding the particulars of the medical literature, guidelines, and the presented cases. Or, perhaps there was a difference in philosophical and moral posture to "fighter cancer harder." If the latter, we believe they could have been influenced by the attitude conveyed by the authors' language. When faced with grave decisions, physicians can be subject to bias: namely, that even if considered equivalent by guidelines, a more "aggressive" therapy (surgery in this instance) confers greater value (or perhaps is more "valiant") than other options, thereby reducing regret. The authors' claim that their "comprehensive approach" has accounted for both the "type 1 and 2 cognitive components" (i.e., emotional and analytical) of decision making is not supported. Given that any statistical analysis is only as good as its inputs, we suggest increased vigilance regarding the use of descriptive language for clinical inputs in future study, with parallel and value neutral word choice wherever possible. And, we interpret these results to suggest that surgeons and hepatologists overwhelmingly agree on the management of intermediate‐stage HCC.