The Care Pathway Revolution in Peritoneal Surface Oncology
Introduction: When the paradigm truly shifts
For decades, a diagnosis of Peritoneal Surface Malignancies (PSM) — traditionally labeled as peritoneal carcinomatosis — was synonymous with therapeutic futility. Treatment strategies were largely palliative, fragmented, and associated with limited survival benefit. Median overall survival rarely exceeded six months, accompanied by high symptom burden and inefficient resource utilization.
Over the last two decades, this narrative has fundamentally changed.
The development of Cytoreductive Surgery (CRS) combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC) and, more recently, Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) has transformed peritoneal oncology into a highly specialized field with curative potential in selected patients.
However, advanced technology alone does not guarantee meaningful outcomes.
To translate innovation into real survival benefit, predictable outcomes, and financial sustainability, a new organizational model is required: an Integrated Care Pathway for Peritoneal Surface Malignancies.
1. The hidden epidemiological and economic burden of peritoneal disease
Peritoneal surface malignancies represent a heterogeneous group of diseases, including:
- Primary tumors, such as Diffuse Malignant Peritoneal Mesothelioma and Primary Peritoneal Carcinoma
- Secondary peritoneal metastases, most commonly arising from:
- Ovarian cancer (60–70%)
- Gastric cancer (15–43%)
- Colorectal cancer (4–15%)
Based on national cancer incidence data, a healthcare provider covering 100,000 insured lives can expect approximately 10–11 new high-complexity peritoneal oncology cases per year.
The true challenge, however, lies not in incidence alone, but in how these patients navigate the healthcare system when no structured care pathway exists.
Without coordination, patients frequently experience:
- repeated hospital admissions,
- acute bowel obstruction,
- ICU utilization,
- emergency surgical procedures with limited oncologic benefit.
This leads to what can be defined as “blind claims burden” — high costs without strategy, measurable outcomes, or long-term value.
2. Centralization, expertise, and patient selection: where prognosis is truly defined
Robust evidence demonstrates that the most critical prognostic factor in peritoneal surface malignancies is the achievement of Complete Cytoreduction (CC-0).
High-volume centers with dedicated multidisciplinary teams consistently achieve CC-0 rates between 92% and 97%, translating into significantly improved survival compared to low-volume institutions.
An integrated care pathway ensures that:
- every patient is evaluated within a multidisciplinary Tumor Board,
- surgical candidacy is defined using Peritoneal Cancer Index (PCI), tumor biology, and treatment intent,
- staging laparoscopy is systematically employed when appropriate.
This structured approach avoids futile laparotomies, which may occur in up to 38% of cases when patients are not adequately selected, protecting both patients and healthcare systems from unnecessary harm and cost.
3. Prehabilitation: the cornerstone of high-complexity risk management
CRS and HIPEC are among the most demanding procedures in surgical oncology, with average operative times of 8 to 10 hours. In this setting, multimodal prehabilitation is no longer optional — it is a critical risk mitigation strategy.
Comprehensive prehabilitation programs incorporating:
- supervised physical exercise,
- nutritional optimization,
- psychological and medical support,
have been shown to:
- reduce direct hospital costs by an average of US$ 2,308 per patient,
- shorten length of stay by approximately two days,
- significantly decrease severe postoperative complications (Clavien–Dindo grade III–IV).
Each avoided major complication represents a substantial economic and clinical benefit, often exceeding US$ 13,000 per event, while simultaneously improving patient experience and recovery.
Prehabilitation transforms high-complexity surgery into a controlled, predictable, and value-driven process.
4. Value-based medicine: when complexity and sustainability align
When delivered within a structured care pathway, peritoneal surface oncology shifts from a cost-centered model to a value-based framework.
Well-organized programs demonstrate:
- positive institutional financial margins for CRS and HIPEC, particularly in open-account or referral-based models,
- strong cost-effectiveness profiles, especially in ovarian cancer, where the addition of HIPEC during interval debulking surgery yields exceptionally low incremental cost-effectiveness ratios (ICERs), well below internationally accepted thresholds,
- reduced litigation risk, improved patient satisfaction, and enhanced predictability of care delivery.
Value-based healthcare does not mean spending less — it means investing strategically, guided by evidence, outcomes, and long-term impact.
5. Survivorship and prevention: consolidating long-term return on investment
The patient journey does not end at hospital discharge.
Structured survivorship programs, particularly those centered on lifestyle medicine, have demonstrated profound oncologic impact. The CHALLENGE trial (NEJM, 2025) showed that a structured post-treatment exercise program reduced the relative risk of cancer recurrence or death by 28%, achieving over 90% overall survival at eight years.
Looking ahead, integrated care pathways must expand toward primary and secondary prevention, including:
- structured physical activity programs,
- genetic risk assessment (e.g., BRCA mutations, Lynch syndrome),
- early intervention strategies in high-risk populations.
This evolution transforms healthcare organizations from passive payers into active stewards of long-term health outcomes.
Conclusion: leadership, strategy, and the future of peritoneal oncology
Implementing an Integrated Care Pathway for Peritoneal Surface Malignancies is not merely a clinical decision — it is a strategic leadership choice.
By aligning:
- certified technical expertise,
- rigorous multidisciplinary selection,
- structured prehabilitation,
- longitudinal survivorship care,
high-cost, high-risk cases can be transformed into units of measurable value, curative intent, and sustainable healthcare delivery.
Peritoneal oncology has already evolved.
Now, healthcare systems must evolve with it.
Dr. Artur Chagas Vilela dos Reis
Specialist in Peritoneal Surface Malignancies (ESPSO / ESSO)
