A comprehensive set of new clinical guidelines for peritoneal surface malignancies has been published, marking the first major update since the 2018 Chicago Consensus and addressing critical care gaps for approximately 70,000-80,000 patients affected annually in the United States.
The updated guidelines, led by Kiran Turaga, MD, MPH, professor of surgical oncology and division chief of Surgical Oncology and Surgery at Yale Cancer Center, represent a significant advancement in addressing the unique challenges faced by patients with peritoneal metastases from gastrointestinal and gynecologic cancers, as well as primary peritoneal malignancies like mesothelioma.
Enhanced Methodology and Representation
Unlike the 2018 Chicago Consensus, which aimed to reduce nihilism and variation in care but had limited adoption, the new guidelines employed a methodologically rigorous Delphian process with rapid reviews resembling systematic reviews for each disease type. The consortium expanded significantly to include a larger group of researchers, clinicians, pathologists, surgical oncologists, and medical oncologists.
"The key difference was that we also had patient representatives. Every disease site had a patient group that represented their perspective and stakeholders. We had international stakeholders, people from different parts of the world," Turaga explained.
The guidelines received endorsement from the Society of Surgical Oncology, the premier surgical oncology association, and have been adopted into the NCCN guidelines, addressing a major limitation of the previous consensus.
Addressing Critical Clinical Challenges
Peritoneal surface malignancies present unique diagnostic and treatment challenges that the guidelines specifically address. The primary issue is imaging difficulty, as peritoneal metastases are often not visible on standard CT scans, leading to delayed diagnosis and advanced disease presentation.
"The challenge with peritoneal metastases is that they're difficult to image on scans. What ends up happening is that, many times, patients are excluded from clinical trials," Turaga noted. Research examining 50,000 colon cancer patients found that barely anyone with peritoneal metastases was enrolled in clinical trials.
This imaging limitation creates a dangerous clinical scenario where patients appear to be doing well during routine oncology visits, only to suddenly present with bowel obstructions and rapidly deteriorating conditions. "The patients are feeling great, they come for their oncology visits, they feel like they're doing okay, and then suddenly they're there with bowel obstructions, and are going to hospice or are dying," Turaga described.
Comprehensive Treatment Framework
The new guidelines consist of seven papers examining different treatment pathways, published jointly in Cancer and the Annals of Surgical Oncology. This comprehensive approach addresses the distinct management needs of peritoneal metastases patients who are often excluded from clinical trials and present with advanced disease by the time specialists become involved.
Training and Standardization Focus
A major emphasis of the guidelines is improving oncologist training for peritoneal surface malignancies. The guidelines promote the use of common terminology to help trainees better understand and communicate various aspects of the disease, addressing the current landscape where training opportunities are limited.
The methodological rigor of the current guidelines, combined with patient representation and alignment with major national organizations, represents a significant departure from previous efforts and positions these guidelines for broader adoption and impact in clinical practice.
