Abstract
Background
When treating potentially resectable pancreatic adenocarcinoma, therapeutic decisions
are left to the sensibility of treating clinicians who, faced with a decision that
post hoc can be proven wrong, may feel a sense of regret that they want to avoid.
A regret-based decision model was applied to evaluate attitudes toward neoadjuvant
therapy versus upfront surgery for potentially resectable pancreatic adenocarcinoma.
Methods
Three clinical scenarios describing high-, intermediate-, and low-risk disease-specific
mortality after upfront surgery were presented to 60 respondents (20 oncologists,
20 gastroenterologists, and 20 surgeons). Respondents were asked to report their regret
of omission and commission regarding neoadjuvant chemotherapy on a scale between 0
(no regret) and 100 (maximum regret). The threshold model and a multilevel mixed regression
were applied to analyze respondents’ attitudes toward neoadjuvant therapy.
Results
The lowest regret of omission was elicited in the low-risk scenario, and the highest
regret in the high-risk scenario (P < .001). The regret of the commission was diametrically opposite to the regret of
omission (P ≤ .001). The disease-specific threshold mortality at which upfront surgery is favored
over the neoadjuvant therapy progressively decreased from the low-risk to the high-risk
scenarios (P ≤ .001). The nonsurgeons working in or with lower surgical volume centers (P = .010) and surgeons (P = .018) accepted higher disease-specific mortality after upfront surgery, which resulted
in the lower likelihood of adopting neoadjuvant therapy.
Conclusion
Regret drives decision making in the management of pancreatic adenocarcinoma. Being
a surgeon or a specialist working in surgical centers with lower patient volumes reduces
the likelihood of recommending neoadjuvant therapy.
Graphical abstract
Graphical Abstract
To read this article in full you will need to make a payment
Purchase one-time access:
Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online accessOne-time access price info
- For academic or personal research use, select 'Academic and Personal'
- For corporate R&D use, select 'Corporate R&D Professionals'
Subscribe:
Subscribe to SurgeryAlready a print subscriber? Claim online access
Already an online subscriber? Sign in
Register: Create an account
Institutional Access: Sign in to ScienceDirect
References
- Neoadjuvant therapy followed by resection versus upfront resection for resectable pancreatic cancer: a propensity score matched analysis.J Clin Oncol. 2017; 35: 515-522
- Comparative effectiveness of neoadjuvant therapy and upfront resection for patients with resectable pancreatic adenocarcinoma: an instrumental variable analysis.Ann Surg Oncol. 2021; 28: 3186-3195
- Safety and efficacy of pre-operative or postoperative chemotherapy for resectable pancreatic adenocarcinoma (PACT-15): a randomised, open-label, phase 2-3 trial.Lancet Gastroenterol Hepatol. 2018; 3: 413-423
- Trial sequential analysis of randomized controlled trials on neoadjuvant therapy for resectable pancreatic cancer.Eur J Surg Oncol. 2022; 48: 1994-2001
- Eliciting regret improves decision making at the end of life.Eur J Cancer. 2016; 68: 27-37
- Acceptable regret model in the end-of-life setting: patients require high level of certainty before forgoing management recommendations.Eur J Cancer. 2017; 75: 159-166
- When to perform hepatic resection for intermediate-stage hepatocellular carcinoma.Hepatology. 2015; 61: 905-914
- Defining optimum treatment of patients with pancreatic adenocarcinoma using regret-based decision curve analysis.Ann Surg. 2014; 259: 1208-1214
- Thinking styles and regret in physicians.PLoS One. 2015; 10e0134038
- How do physicians decide to treat: an empirical evaluation of the threshold model.BMC Med Inform Decis Mak. 2014; 14: 47
- Consolidated criteria for reporting qualitative research (COREQ): a 32-item checklist for interviews and focus groups.Int J Qual Health Care. 2007; 19: 349-357
- A regret theory approach to decision curve analysis: a novel method for eliciting decision makers’ preferences and decision-making.BMC Med Inform Decis Mak. 2010; 10: 51
- The threshold approach to clinical decision making.N Engl J Med. 1980; 302: 1109-1117
- Value-induced bias in medical decision making.Med Decis Making. 2008; 28: 269-276
- Clinical calculator of conditional survival estimates for resected and unresected survivors of pancreatic cancer.Arch Surg. 2012; 147: 513-519
- Systematic review of clinical prediction models for survival after surgery for resectable pancreatic cancer.Br J Surg. 2019; 106: 342-354
- Many faces of rationality: implications of the great rationality debate for clinical decision-making.J Eval Clin Pract. 2017; 23: 915-922
- Rational decision making in medicine: implications for overuse and underuse.J Eval Clin Pract. 2018; 24: 655-665
- NCCN guidelines for patients: pancreatic cancer; 2021.https://www.nccn.org/patients/guidelines/content/PDF/pancreatic-patient.pdfDate accessed: April 25, 2022
- ESMO Guidelines Committee. Cancer of the pancreas: ESMO Clinical Practice Guidelines for diagnosis, treatment and follow-up.Ann Oncol. 2015; 26: v56-v68
- Prognostic nomogram for patients undergoing resection for adenocarcinoma of the pancreas.Ann Surg. 2004; 240: 293-298
- Impact of centralization of pancreatic cancer surgery on resection rates and survival.Br J Surg. 2014; 101: 1000-1005
- Centralization of pancreatic cancer treatment within an integrated healthcare system improves overall survival.Am J Surg. 2022; 223: 1035-1039
- The perceived ability of gastroenterologists, hepatologists and surgeons can bias medical decision making.Int J Environ Res Public Health. 2020; 17: 1058
Article info
Publication history
Published online: March 15, 2023
Accepted:
January 17,
2023
Publication stage
In Press Corrected ProofIdentification
Copyright
© 2023 Elsevier Inc. All rights reserved.
