Determining Chances for Survival in Intrahepatic Cholangiocarcinoma
Authors: Jake E. Krige, Delawir Kahn
Journal: JAMA Surgery (2015)

As a patient might ask, “Doctor, now that you have successfully removedmy liver cancer, what are my chances?” “Weareverypleased that youhave recovered sowell from the operation but, unfortunately, aswehave discussed previously, this is a seriouscancerandweknowthatasmanyas twothirds of patients die within the first 2 years. However, if you are alive after 3 years, your chances of long-term survival are good,” might be a physician’s response. The latter part of this fictitious conversation seldom occurs with conviction because of the absence of robust longtermdata for intrahepatic cholangiocarcinoma.Therefore, this multicenter study by Spolverato et al1 is relevant and opportune because epidemiologic data showasubstantial global increase in age-adjusted mortality for this carcinoma. Prognostic factorsassociatedwith recurrenceandreducedsurvival after resection include tumor size, vascular invasion, lymphnodemetastases,multiple tumors, andAmerican Joint Committee on Cancer stage.2,3 In the cohort of patients who, despite pessimistic prognostic factors, beat the odds and survive longer, outcomesurpassesandbecomesunfetteredby the original prognostic factors. In high-risk patients with cancer who traditionally have a poor prognosis, conditional survival may provide a useful tool as overall outcome may be prejudiced by conventional prognostic criteria and the substantial number of patients who die in the first few years. Relative conditional survival data may offer valuable information, especially for poor-risk category survivors of cancer who surpass their initial predicted duration of survival. For some categories of tumors, such as testicular or thyroid cancer, less intense surveillance may be justified when survival reaches a plateau after 2 to 3 years with no substantial increase in mortality thereafter. In contrast, while the greatest risk to survival is in the first few years for patients with more aggressive tumors, such as pancreas, lung, or breast cancer, the survivors still require sustained and prolonged surveillance, extending to 10 years and beyond because of inexorable attrition rates. The continued decline in overall survival in this high-risk cohort compared with a similarly aged general population is usually explained by late recurrence, development of secondary tumors, delayed adverse reaction to treatment, or the consequences of greater comorbidity in elderly individuals. Is conditional survival a new or novel concept? Surgeons have known intuitively for decades that it is logical (and common sense) that the longer a patient survives without evidence of recurrence after cancer resection, the greater the chances of deferred recurrence or indeedpossible cure. Some would argue that conditional survival uses a biased advantage by deferring a decision and later identifying and selecting survivorswhowill invariably do better than the initial cohort inwhomsurvivorship is diminished by including overall mortality. Thedrawbacks of conditional survival data are that increasingly accurate information is delayed and only becomes available with the passage of time, during which precision is augmented by using progressive chronological data maturity. In contrast, traditional prognostic scoring systems arederived frominformationobtainedsolelyat the timeof surgery and therefore become increasingly inaccurate as time passes from the inception of surgical intervention. Hopefully, in the future, additional prognostic factors, including tumor biomarkers, will allow ab initio identification of longterm survivors.