COMMENTARY

New Approaches Needed for Peritoneal Metastases in CRC

David J. Kerr, CBE, MD, DSc, FRCP, FMedSci

Disclosures

April 13, 2017

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Hello. I am David Kerr, professor of cancer medicine from the University of Oxford, in Oxford, England.

The Lancet Oncology has recently published a very nice paper from the ARCAD group.[1] Their study looked at individual patient data from a large number of well-designed clinical trials of patients with advanced colorectal cancer. They wanted to examine the impact of peritoneal disease on overall survival response to chemotherapy. This is something we have talked about and discussed previously.

[P]eritoneal metastases are bad news.

The study comprised a very large dataset of about 20,000 patients. As with previous studies, this one showed consistently, and perhaps not surprisingly, that peritoneal metastases are bad news and they do carry a worse prognosis. The investigators performed substantial multivariable modeling for a number of metastatic sites, which was not hugely informative. They also did a small amount of molecular biology work, but the numbers were too small to be useful or interesting. Thus, here we are, with a very large, well-designed study showing again that peritoneal metastases are bad news.

I wonder whether we need to pay more attention and consider more aggressive means of looking at peritoneal disease. Of course, we have the surgical approach of peritonectomy and of using intraperitoneal chemotherapy plus or minus hyperthermia.[2] Although we have wonderful surgical advocates for this approach, the randomized trial data supporting these expensive, complicated interventions are singularly lacking.[3] The problem is that because this approach is multimodal—surgery, intraperitoneal chemotherapy, hyperthermia, a bit of this, and a bit of that—it is often very difficult to discern what the key contributory elements are in this whole therapeutic cascade.

What should we do? I believe we need to seriously get together and plan some decent studies so that we can disentangle the different elements of these rather overcomplicated approaches to peritoneal disease. I am not saying that this is a trivial question. I am not saying that we do not need to bring more firepower to bear. But I would like to use these treatments rationally, sequentially, and sensibly so that we can prove that adding hyperthermia, adding different chemotherapy agents, doing this, and doing that genuinely takes us an incremental step forward rather than buying into a whole package of care that has never been subjected to any meaningful randomized trial. A serious condition requires a serious, thoughtful, logical approach.

Let me use this brief video as our call to arms, if I may use that term, to bring a community of those who have interest in advanced colorectal disease together to pay more attention to peritoneal disease. By doing so, let us see if we can come up with some rational trials to which we, the wider oncology community, will recruit so that we can understand better the biology of the disease and come up with rational therapeutic options.

Thanks for listening.

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