Dear Editor,
We have read a recent paper by Ho et al. published in the Clinical and Molecular Hepatology, with great interest [1]. This significant study developed and validated two risk scores which predict overall survival (OS) among patients with early-stage hepatocellular carcinoma (HCC). We appreciate the rigorous effort of this study. However, we would like to raise the following comments for further discussion:
First, non-liver-related death should be considered as a competing event when competing risk analysis is performed as a sensitivity analysis. Despite the fact that patients with early-stage HCC primarily die from liver-related events, we suggest a competing risk model to reduce potential risk overestimation in populations where the risk of competing events is high [2-5]. The value of this method may be further clarified with the same survival data in this study.
Second, the authors’ inclusion of important information such as demographic information and laboratory tests to adjust for potential covariates is commendable. However, considering other potential confounders such as the presence of prophylactic antiviral treatment, treatment methods, Charlson Comorbidity Index and family income might further enhance the robustness of these findings [6,7].
Last, to our knowledge, a recent study has revealed the association of sex with survival in HCC patients [8]. Given the controversy about the effect of sex on HCC survival, a separate analysis for the subgroup could offer more nuanced insights.
This article is a significant step forward in our understanding of the roles of risk scores in OS prediction for early-stage HCC patients. A more comprehensive prediction could be an intriguing topic for further investigation.
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