Implementing New Peritoneal Surface Malignancy Care Guidelines Nationally

According to Kiran Turaga, MD, MPH, peritoneal surface malignancy care is a field that is highly opinionated, where some experience epistemic closure. New guidelines for care aim to absolve some of that by unifying clinicians behind specific methods of care.

Turaga, division chief of Surgical Oncology and Surgery, assistant medical director of the Clinical Trials Office, and a professor of surgical oncology, at Yale Cancer Center, and the research lead of the team that put together these guidelines, discussed this issue of epistemic closure as one of the largest problems to implementing these new guidelines into oncology institutions. One example he gave was the doctors who prefer surgery vs the doctors who prefer chemotherapy.

As Turaga said, even amidst the creation of the guidelines, there were several strong schools of thought amongst the 500 experts who contributed to the creation of the guidelines. Despite this, they couldn’t alter the guideline they were creating because of their personal beliefs.

Two other barriers Turaga mentioned are being able to disseminate these guidelines broadly, so everyone can access them, and then the insurance companies, because they have strict policies surrounding which treatment modality specific patients can receive.

Transcript:

The first and biggest challenge is that this is a very opinionated field. There is something called epistemic closure, where people believe something, and it is very difficult for them to break their beliefs. This is part of our training. This is part of the history of how peritoneal surface malignancies have been approached in the US. There are people who feel like…surgery is very good, and people who feel chemotherapy is very good. It almost seems like people used to be at loggerheads trying to figure out [whose right]. Overcoming that epistemic closure to say, “Hey, listen, let’s think about this together. There is evidence for this, and there isn’t evidence for this” is how we can think about it together, so we can move the field forward. That’s one of the biggest challenges. If we can overcome that inherent bias that all doctors who treat these types of cancers have, it would make a difference, and we see that in some guidelines. We tried to align this with a certain group of guidelines, and despite us being a group of 500 experts who deal with this disease and advocating, and having reviews, we couldn’t change the particular guideline we were trying to align with because of the very strong visceral beliefs that a lot of the physicians had in terms of how to care for it. That would be the biggest challenge for us in adoption.

Secondly, just disseminating this widely. This was a group of us who are interested in peritoneal surface disease, and we certainly published this in both the journals of the American Cancer Society and the Society of Surgical Oncology. Spreading the word across and getting it to everyone is always a difficult process, so we’re hoping the national endorsements will help.

The third barrier is insurance companies. A lot of insurance companies have very specific, rigid policies around care for these patients, and trying to advocate to them to say, “Hey, these patients benefit from these therapies, and this is the evidence for it,” is also another barrier that we anticipate in the dissemination of these [guidelines].

Reference

Butensky SD, Bansal VV, Su DG, et al. Consensus guideline for the management of gastric cancer with synchronous peritoneal metastases. Ann Surg Oncol. Published online June 25, 2025. doi:10.1245/s10434-025-17361-2