The readership should appreciate that I thought Dr. Strasberg’s manuscript to be comprehensive, thoughtful, and well written. He did comment in the discussion “a subtle but important point is that FDG-PET is not improving survival by itself.” My issue was that it was impossible for a diagnostic test per se to directly influence survival.

As judged by others, surgeons have been strongly criticized for their descriptive attempts at surgical research. I believe it is fair to say that we have some experience with the difficulties of randomized trials, but have continued to try to perform them. I do applaud Dr. Strasberg’s attempts to convince the American College of Surgeons Oncology Group to perform a randomized Phase III trial, and am personally disappointed that they concluded, “that the data were so convincing that a Phase II study, rather than a randomized Phase III trial, was recommended.” The literature is replete with promising phase II studies, subsequently disproved by randomized trials.

It was my intent to provide encouragement for surgeons in general to take a leadership role in the validation of tests that we use. It appears, however, that I have unnecessarily and unintentionally provoked Dr. Strasberg.

Mr. Park, Ms. Schwimmer and Dr. Gambhir write to try to clarify issues that I failed to understand in their manuscript. As I pointed out, I did find the manuscript difficult to read, and other readers can make their own judgment. I still favor clarity over prolixity.

I have read and reread the explanation. Unfortunately, I still have a problem. If the overall increase in life expectancy is an average of 9 days, but some patients may live 5 years, then must not other patients live less than the average 9 days? I can only leave the readers to decide whether the manuscript and the added explanation is clear enough to allow us to accept the author’s conclusions. It is encouraging that Dr. Gambhir and his colleagues support the concept of a randomized trial.

If we take Dr. Strasberg’s definition of an editorial, it seems that we fulfilled all of his requirements, and if we allow that an editorial should provoke vigorous debate, it may have been valuable.

Let there be no mistake, we need manuscripts that examine critically the value of technological advances measured in terms of patient care benefit.

Our problem is to prove to other than ourselves that we have established such benefit.