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Intermediate-stage HCC—upfront resection can be feasible

Nature Reviews Clinical Oncology volume 12, page 295 (2015)Cite this article

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We would like to thank Zhong et al. for their Correspondence (Intermediate-stage HCC—upfront resection can be feasible. Nat. Rev. Clin. Oncol. doi:10.1038/nrclinonc.2014.122-c3; 2014)1 on our recent Review (Treatment of intermediate-stage hepatocellular carcinoma Nat. Rev. Clin. Oncol. 11, 525–535; 2014).2 In this letter, Zhong et al. questioned the role of transarterial chemoembolization (TACE) as the standard treatment for intermediate-stage hepatocellular carcinoma (HCC); they suggest that hepatic resection can provide better outcomes than TACE and should be considered the first-line therapy for most patients with intermediate-stage disease.1 Zhong and co-workers suggest that the evidence supporting TACE as an effective therapy is not strong enough, according to the results of a Cochrane systematic review and meta-analysis.3 Regrettably, this meta-analysis has several methodological flaws, such as the inclusion of trials without adequate control arms or studies with inappropriate target populations, that challenge this conclusion.4,5

Zhong and colleagues1 justify the use of hepatic resection based on several retrospective studies that reported better survival outcomes for this modality than TACE in patients with intermediate-stage HCC. Unfortunately, as we have highlighted in a previous comment (Reply: Heterogeneity of intermediate-stage HCC necessitates personalized management including surgery. Nat. Rev. Clin. Oncol. 12, 10; 2014),6 all of these retrospective comparisons were almost certainly associated with selection bias: the patients who were selected for resection instead of TACE probably had clinical characteristics that gave the surgeon confidence of a good outcome, whereas those selected for TACE likely lacked such features, immediately introducing a bias against TACE.7 Ideally, rather than conducting retrospective analyses of studies associated with biases that prompt flawed messages, it would be desirable for such centres of excellence that treat a high volume of patients to initiate properly designed randomized controlled trials, to promote evidence-based medicine and increase the amount of robust data available.

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References

  1. Zhong, J.-H., Lu, S.-D., Wang, Y.-Y., Ma, L. & Li, L.-Q. Intermediate-stage HCC—upfront resection can be feasible. Nat. Rev. Clin. Oncol. http://dx.doi.org/10.1038/nrclinonc.2014.122-c3 (2015).

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Authors and Affiliations

  1. Barcelona Clinic Liver Cancer (BCLC) group, Liver Unit, Networked Biomedical Research Centre for Hepatic and Digestive Diseases (CIBERehd), Hospital Clinic Barcelona, August Pi i Sunyer Biomedical Research Institute (IDIBAPS), University of Barcelona, Carrer Villarroel 170, 08036, Barcelona, Spain

    Alejandro Forner & Jordi Bruix

  2. Department of Medical Oncology, Institut Paoli-Calmettes, 232 Boulevard de Sainte Marguerite, 13009, Marseille, France

    Marine Gilabert & Jean-Luc Raoul

Authors
  1. Alejandro Forner
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  2. Marine Gilabert
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Correspondence to Alejandro Forner.

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Competing interests

A.F. has acted as a consultant for Bayer HealthCare. J.B. has acted as a consultant or in an advisory role for ArQule, Bayer, Biocompatibles, Bristol–Myers Squibb, Celgene, Daiichi-Sankyo, Kowa, Lilly, Novartis, Roche, and Terumo. J.-L.R. has acted as a consultant or in an advisory role for Arqule, Bayer HealthCare, Biocompatibles, Bristol–Myers Squibb, and Merck Serono. M.G. declares no competing interests.

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Forner, A., Gilabert, M., Bruix, J. et al. Intermediate-stage HCC—upfront resection can be feasible. Nat Rev Clin Oncol 12, 295 (2015). https://doi.org/10.1038/nrclinonc.2014.122-c4

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