Peritoneal Surface Malignancy Program Research Articles

ASO Visual Abstract: Cost Analysis and Financial Implications of a Peritoneal Surface Malignancy Program in the United States.

ASO Visual Abstract: Cost Analysis and Financial Implications of a Peritoneal Surface Malignancy Program in the United States.

Cost Analysis and Financial Implications of a Peritoneal Surface Malignancy Program in the USA.

We aimed to describe the financial implications of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (CRS/HIPEC) in the USA. We conducted a retrospective cost analysis of 100 CRS/HIPEC procedures to examine the impact of patient and procedural factors on hospital costs and reimbursement. A comparison of surgeons' work relative value units (wRVUs) between CRS/HIPEC and a representative sample of complex surgical oncology procedures was made to assess the physicians' compensation rate. Univariable and multivariable backward logistic regression was used to analyze the association between perioperative variables and high direct cost (HDCs). The median direct cost per CRS/HIPEC procedure was US $44,770. The median hospital reimbursement was US $43,066, while professional reimbursement was US $8608, resulting in a positive contribution margin of US $7493/procedure. However, the contribution margin significantly varied with the payer mix. Privately insured patients had a positive median contribution margin of US $23,033, whereas Medicare-insured patients had a negative contribution margin of US $13,034. Length of stay (LOS) had the most significant association with HDC, and major complications had the most significant association with LOS. Finally, CRS/HIPEC procedures generated a median of 13 wRVU/h, which is significantly lower than the wRVU/h generated by open pancreatoduodenectomies, open gastrectomies, and hepatectomies. However, higher operation complexity and multiple visceral resections help compensate for the relatively low wRVU/h. CRS/HIPEC is an expensive operation, and prolonged LOS has the most significant impact on the total cost of the procedure. High-quality care is essential to improve patient outcomes and maintain the economic sustainability of the procedure.

Prognostic Value of En-Block Radical Bowel Resection in Advanced Ovarian Cancer Surgery With HIPEC.

To identify prognostic factors of survival and recurrence in advanced ovarian cancer patients undergoing radical surgery and HIPEC. In a single Department of Surgical Oncology, Peritoneal Surface Malignancy Program, and over a 16-year period, from a total of 274 epithelial ovarian cancer patients, retrospectively, we identified 152 patients undergoing complete (CC-0) or near-complete (CC-1) cytoreduction, including at least one colonic resection, and HIPEC. Mean age of patients was 58.8years and CC-0 was possible in 72.4%. Rates of in-hospital mortality and major morbidity were 2.6% and 15.7%. Only 122 (80.3%) patients completed Adjuvant Systemic Chemotherapy (ASCH). Rates of metastatic Total Lymph Nodes (TLN), Para-Aortic and Pelvic Lymph Nodes (PAPLN) and Large Bowel Lymph Nodes (LBLN) were 58.7%, 58.5%, and 51.3%, respectively. Median, 5- and 10-year survival rates were 39months, 43%, and 36.2%, respectively. The recurrence rate was 35.5%. On univariate analysis, CC-1, high Peritoneal Cancer Index (PCI), in-hospital morbidity, and no adjuvant chemotherapy were adverse factors for survival and recurrence. On multivariate analysis, negative survival indicators were the advanced age of patients, extensive peritoneal dissemination, low total number of TLN and no systemic PAPLN. Metastatic LBLN and segmental resection of the small bowel (SIR) were associated with a high risk for recurrence. CC-O is feasible in most advanced ovarian cancer patients and HIPEC may confer a survival benefit. Radical bowel resection, with its entire mesocolon, may be necessary, as its lymph nodes often harbor metastases influencing disease recurrence and survival. The role of metastatic bowel lymph nodes has to be taken into account when assessing the impact of systemic lymphadenectomy in this group of patients.

Feasibility and outcomes of cytoreductive surgery and HIPEC for peritoneal surface malignancies in low- and middle-income countries: a single-center experience of 232 cases

BackgroundCytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) has recently emerged as a viable management option for peritoneal surface malignancy (PSM). CRS and HIPEC is a complex, multidisciplinary and resource-intensive surgical procedure. It has a steep learning curve and is associated with significant morbidity and mortality. The expertise is mostly limited to few dedicated high-volume centers located in developed countries. We present a single institutional experience of 232 cases of CRS and HIPEC performed at a tertiary care cancer center in a low- and middle-income country (LMIC).MethodsA multidisciplinary PSM program was initiated in 2015 at a high-volume public-sector tertiary care cancer center in North India catering largely to patients belonging to low- and middle-income groups. Perioperative protocols were developed, and a prospective structured database was created to capture data. All patients undergoing CRS and HIPEC between January 2015 and December 2020 were identified, and the data was retrospectively analyzed for clinical spectrum, surgical details, and perioperative morbidity and mortality.ResultsTwo hundred and thirty-two patients underwent CRS and HIPEC during the study period. Epithelial ovarian carcinoma (56.5%) was the most common malignancy treated, followed by pseudomyxoma peritonei (18.5%), colorectal carcinoma (13.4%), and malignant mesothelioma (5.6%). Optimal CRS could be achieved in 94.4% of patients. Cisplatin and mitomycin were the most common drugs used for HIPEC. A total of 28.0% of patients had morbidity including deep vein thrombosis, subacute intestinal obstruction, sepsis, burst abdomen, lymphocele, urinoma, acute renal failure, and enterocutaneous fistula. The overall treatment-related mortality was 3.5%.ConclusionsResults of the current study indicate that it is feasible to establish a successful CRS and HIPEC program for PSM in government-funded hospitals in LMIC facing resource constraints. The most common indication for CRS and HIPEC were carcinoma of the ovary followed by pseudomyxoma peritonei and colorectal carcinoma. Overall morbidity and mortality in the current series are comparable to global standards, reported from high-income countries. A protocol-based multidisciplinary team approach, optimal patient selection, and surgical expertise can help achieve optimal outcomes in government-funded hospitals in LMIC.

Twelve-Year Single Center Experience Shows Safe Implementation of Developed Peritoneal Surface Malignancy Treatment Protocols for Gastrointestinal and Gynecological Primary Tumors.

Simple SummaryThe treatment of peritoneal surface malignancies (PSM) has dramatically evolved during the past two decades. Indications, treatment protocols, surgical techniques and the application of HIPEC in the prophylactic setting were evaluated in the surgical community. Nevertheless, the current results of the PRODIGE-7 trial disfavored the application of HIPEC for PSM of colorectal cancer and raised uncertainty among surgeons. On the other hand, cytoreductive surgery and HIPEC represent state-of-the-art therapy for peritoneal mesothelioma (except the sarcomatoid-subtype) and pseudomyxoma peritonei. Comparing the literature is cumbersome due to the variety of HIPEC protocols and differences in indication settings. This article aims to provide an insight into the impact of different HIPEC protocols, different indication settings and the implementation of pre-HIPEC laparoscopy on patients’ morbidity rates and outcomes and serves as guidance for surgeons dealing with these patients in order to guarantee high-quality treatment.(1) Background: Cytoreductive surgery and hyperthermic intraperitoneal chemotherapy provide survival benefits to selected patients. We aimed to report our experience and the evolution of our peritoneal surface malignancy program. (2) Methods: From June 2005 to June 2017, 399 patients who underwent cytoreductive surgery plus hyperthermic intraperitoneal chemotherapy at the Tübingen University Hospital were analyzed from a prospectively collected database. (3) Results: Peritoneal metastasis from colorectal cancer was the leading indication (group 1: 28%; group 2: 32%). The median PCI was 15.5 (range, 1–39) in group 1 and 11 (range, 1–39) in group 2 (p = 0.002). Regarding the completeness of cytoreduction (CC), a score of 0 was achieved in 63% vs. 69% for group 1 and 2, respectively (p = 0.010). Median overall survival rates for patients in group 1 and 2 for colon cancer, ovarian cancer, gastric cancer and appendix cancer were 34 and 25 months; 45 months and not reached; 30 and 16 months; 39 months and not reached, respectively. The occurrence of grade-III and -IV complications slightly differed between groups (14.5% vs. 15.6%). No 30-day mortality occurred. (4) Conclusions: Specialized centers are able to provide low-morbidity cytoreductive surgery and hyperthermic intraperitoneal chemotherapy without mortality. Strict patient selection during the time period significantly improved CC scores.

Mid-Term Audit of a National Peritoneal Surface Malignancy Program Implementation in a Low Middle Income Country: The Moroccan Experience.

Simple SummaryComplete cytoreductive surgery (CRS) is the backbone of peritoneal surface malignancies (PSM) management and a major prognostic factor to better survival outcomes. Implementing a PSM program is a steep and complex process, particularly in low-middle income countries (LMIC), where limited resources are an additional challenge to overcome. In this study, we present the results of a mid-term audit of the implementation of a PSM program in Morocco. The latter was successfully and safely launched according to predicted initiation, transition and consolidation periods and allowed the significant improvement of short term surgical and oncological outcomes and completeness of cytoreduction procedures.Implementing a multimodal management of peritoneal surface malignancies is a steep and complex process, especially as complete cytoreductive surgery (CRS) is the backbone and the major prognostic factor for hyperthermic intraperitoneal chemotherapy (HIPEC) procedures. The implementation of such a program is a challenging process, particularly in low-middle income (LMIC) countries where ressource restrictions may represent a major hurdle to HIPEC appliances acquisition. Herein is the first audit of the implementation of a national peritoneal malignancy program in a north African country. The audit process was performed according to the three implementation steps, namely initiation (“1”:2005–2008), transition (“2”:2009–2013) and consolidation (“3”:2014–2017). We included all consecutive CRS without HIPEC performed with curative intent for ovarian, gastric, colorectal and pseudomyxoma peritonei type of malignancies with an Eastern Cooperative Oncology Group (ECOG) performance Status ≤ 2. Target outcomes for incomplete cytoreduction (ICRS), serious complications ≥ 3b according to the Clavien-Dindo scoring, and early oncologic failure (EOF; disease progression within 2 years of treatment) were compared between the three phases. Independent risk factors correlated to these three outcomes were calculated using a logistic regression model.198 CRS procedures were completed with 49, 60 and 89 cases performed in the three phases, respectively. Overall, patients were comparable except for ECOG and ASA scores which were more severe in the third phase. The comparison of ICRS, serious complications and EOF rates showed a significant reduction between the three phases with (34%, 18% and 4% p = <0.001), (30.6%, 20% and 11.2%, p = 0.019) and (38.8%, 23.3% and 12.4% p = 0.002) respectively. Undergoing CRS in phase 3 on the other hand was a predictive factor of better short term surgical and oncological outcomes and completeness of cytoreduction, while ECOG performance status and spleno-pancreatectomy were also predictive factors of serious complications.

Establishing of Peritoneal Surface Malignancy Treatment Program: Background in Ukraine, Patient Selection, Staff Schedule, Perioperative Outcomes of First 28 Patients.

A combination of cytoreductive intervention with the intrahepatic hyperthermic chemotherapy is a well-established treatment of peritoneal carcinomatosis. There are many challenges in establishing a new peritoneal surface malignancy program in a low-income country regarding perioperative safety and resource allocation. We analyzed the retrospective database to determine the immediate surgical outcomes of the first 28 patients with peritoneal carcinomatosis and the impact of the program on allocation of general hospital and human resources. During the preparatory stage, web conferences with international experts established the goals and general requirements of the program, formalized in a written document; and a peritoneal surface malignancy multidisciplinary team was established. The team created the patient selection criteria, perioperative management checklists, and suggested material and staff requirements for surgical and anesthesia services. Twenty-nine cytoreduction were carried out, of which 18 were followed by HIPEC. The average operative time was 6.2h. The median blood loss was 350mL, which did not result in additional blood transfusion requirements for the blood bank. No additional nursing and supportive staff were provided for the ICU and the surgical unit. The average postoperative stay was 8.7days. One patient died with 30-day mortality rate of 3%. Ten patients (34.5%) developed postoperative complications, of which 6 (20.6%) had grade III and higher Clavien-Dindo complications. Establishing a peritoneal surface malignancy program is possible via staged planning, liberal use of international mentors, and thoughtful resource allocation. This new program did not result in a significant redistribution of resources among other service lines of cancer care within the same institution.

Implementation and protocol of a peritoneal surface malignancy program in a developing country.

Background: Peritoneal surface malignancy surgery is a technically demanding procedure that implies a thorough planification in multiple areas: safety precaution measures for patients and workers, education of multiple involved physicians, nurses, and support team. Requires also technological implementation, information management, social security conciliation and overall commitment of the surgical team and institution.

Evaluation of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in a community setting: A cost-utility analysis of a hospital's initial experience and reflections on the health care system.

The combination of Cytoreductive Surgery (CRS) plus Hyperthermic Intraperitoneal Chemotherapy (HIPEC) has been gaining a considerable interest by surgeons throughout the United States due to the significant survival improvement it provides for peritoneal surface malignancies and the ability to reproduce comparable clinical results in numerous health care centers. However, CRS plus HIPEC has not been sufficiently investigated from the economic standpoint in the United States where a wide variety of health care insurers exists. This study was conducted to analyze hospital/surgeon cost and reimbursement data at a community hospital offering a new peritoneal surface malignancy program, and expand the discussion to analyze future healthcare implementation on this procedure in the United States. This is a retrospective economic analysis of an initial CRS plus HIPEC experience at a community non-teaching medical center. This study was conducted using hospital/surgeon cost and reimbursement based on the Office of Finance data at Edward Hospital Cancer Center (Naperville, IL). All patients who underwent CRS and HIPEC between June 2013 and August 2014 were included in this analysis. We aimed to assess CRS plus HIPEC purely from the financial perspective on the initial admission regardless of the patients' advancement of the disease or postoperative adverse events. Twenty-five patients underwent 26 CRS plus HIPEC procedures. Twelve patients had private insurance plans (PRV) whereas 13 were covered by public insurers (PUB). Median overall length of stay (LOS) was 10 days (PRV 10 days vs. PUB 11 days; P = 0.76.) Average hospital cost was $38,369 (PRV $37,093 vs. PUB $39,463; P = 0.67), and average reimbursement for our patient population was $45,243 (PRV $48,954 vs. PUB $42,062; P = 0.53). It was noted that CRS plus HIPEC generated more net profit in patients with private insurance than in those with public plans, however, not statistically significant ($11,861 vs. $2,599 per patient, respectively; P = 0.38). Evaluating surgeon's data, average surgeon's charge was $29,139 (PRV $28,440 vs. PUB $29,737; P = 0.80), and average patients' payment was $8,126 (PRV 9,234 vs. PUB 7,176; P = 0.47). CRS plus HIPEC is profitable in the community setting for both the hospital and surgeon. Both private and public insurers reimbursed profitably, though with a greater profit margin from private insurers. As CRS plus HIPEC is becoming more widely recognized as a standard of care for patients with peritoneal surface malignancy, it is increasingly important to understand and report its associated costs and variability in insurance coverage, especially in light of the current healthcare structure changes in the United States. It is strongly encouraged to report and present a wider scope of CRS plus HIPEC economic experiences in a variety of hospital settings to provide further evidence for future healthcare implementations in the United States. J. Surg. Oncol. 2016;113:544-547. © 2016 Wiley Periodicals, Inc.

Morbidity and mortality outcomes of cytoreductive surgery and hyperthermic intraperitoneal chemotherapy in patients with primary and recurrent advanced ovarian cancer

BackgroundThe aim of this study is to report the perioperative outcomes of CRS and HIPEC from a single institution and review those factors that are associated with a poor perioperative outcome in patients with peritoneal dissemination from primary or recurrent ovarian cancer. Patients and methodA retrospective cohort study setting was conducted in a third level hospital peritoneal surface malignancy program. Ninety one patients diagnosed with ovarian peritoneal carcinomatosis, primary and recurrent without extraperitoneal metastasis were included for cytoreductive surgery and HIPEC with paclitaxel. We analyzed the postoperative morbidity rates and a univariate and multivariate analysis of factors associated with overall (grade I–IV) and major (grade III–IV) postoperative morbidity were performed. ResultsPeritoneal Cancer Index (PCI) upper than 12 (OR = 2.942 95%: 1.892–9.594 p = 0.044) was an independent factor associated with the occurrence of I–IV postoperative morbidity. Regarding major complications (grade III–IV), on multivariate analysis, in addition to PCI >12 (OR = 6.692, 95% CI: 1974–45, 674, p = 0.032), the need to carry out intestinal resection (OR = 4.987, 95% CI: 1350–27, 620, p = 0.046) was an independent factor related with major morbidity (grade III–IV). ConclusionsThe use of HIPEC after aggressive cytoreductive surgery in patients with ovarian cancer with peritoneal dissemination can be performed with acceptable postoperative morbidity rates. Knowledge of the factors associated with the onset of these postoperative adverse events allows better management of the same and offers the patient a safe procedure.

Risk factors for recurrence following complete cytoreductive surgery and HIPEC in colorectal cancer-derived peritoneal surface malignancies

Recurrent disease following complete cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) is a relevant clinical scenario. We aimed to determine risk factors for recurrence. Prospectively collected data of patients enrolled in the Peritoneal Surface Malignancy Program at the University of Tübingen between 2005 and 2011 were retrospectively analyzed. All patients were treated by standardized CRS and HIPEC. Recurrence was defined either radiographically by CT, PET-CT scan, or reoperation. Fifty-two patients received complete CRS (CC-0/CC-1) and HIPEC. Median time to recurrence was 229 days (103-1,028). Overall recurrence rate within follow-up was 48 %. Of patients with recurrent disease, 44 % experienced extraperitoneal systemic tumor spread. In multivariate analysis, grading of ≥ 3 was shown as an independent risk factor for recurrent disease, while a trend was observed for maximal tumor load in the upper abdominal region. Clinical parameters did not show an impact on recurrence. Primary tumor grading seems to be an independent risk factor for recurrence following complete CRS and HIPEC in colorectal cancer-derived peritoneal surface malignancies.

The influence of tumor cell entrapment phenomenon on the natural history of Pseudomyxoma peritonei syndrome.

Pseudomyxoma peritonei syndrome (PMP) may be associated with slow "benign" or malignant process. However, the natural history of this disease is slow progression to death. Its treatment is variable and controversial. In this current study we have compared the patients with Pseudomyxoma peritonei syndrome with recurrences due to the cell entrapment hypothesis. Data were derived from a database of patients with PMP treated at our hospitals from 2004 to 2009. All patients had undergone various surgical operations prior to referral to our institutions for definitive treatment. All patients had recurrences in special sites due to entrapment of malignant cells. There are 6 patients, four men and two women. The initial clinical presentation of the disease was hernia in one, appendicitis in three and ovarian mass in one. The mean time from the initial operation to be definitive management was 23.5 months with an average of 1.83 operations per patient. After cytoreduction and hyperthermic intraperitoneal chemotherapy (HIPEC) the mean survival was 31 months with minimal recurrences and only 0.3 operations per patient. Our data suggest that the patients should be referred to a center with a peritoneal surface malignancy program after the PMP diagnosis as soon as possible. Incomplete debulking procedures and minimal invasive operations promote uncontrollable intraabdominal tumor growth due to tumor cell entrapment and the tendency of PMP to grow at wound sites.

The Development of a Peritoneal Surface Malignancy Program: a Tale of Three Hospitals

An increasing amount of evidence supports the use of cytoreductive surgery and heated intraperitoneal chemotherapy (HIPEC) for the treatment of select patients with carcinomatosis. The care of such patients is optimal at centers where physicians with expertise in the recognition, treatment, and follow-up of carcinomatosis collaborate to manage issues particular to patients undergoing HIPEC. New Peritoneal Surface Malignancy Programs should be introduced to meet the growing interest in this field; however, there are few guidelines available on how to propose, develop, and safely implement them across different hospital models. A new Peritoneal Surface Malignancy Program was initiated at a large academic medical center affiliated with three hospital systems serving distinct patient populations: a private hospital, a public hospital, and a Veterans Affairs hospital. Ten groups were identified as playing key roles in program implementation. Program approval was successfully obtained at all three hospitals. The initial two-year experience included a total of 20 cases across the three sites. Six of these cases were aborted due to high tumor volume, most of which (4/6) were at the public hospital. No 30-day mortalities occurred. Hospitals vary significantly in their approval process and timeline for new Peritoneal Surface Malignancy Program development. Patient populations differ in their awareness of HIPEC as a therapeutic modality. Public hospitals may serve patient populations with more advanced disease presentations. Careful coordination by the surgical oncologist with ten key groups allows for the safe introduction of a complex procedure within varied hospital models.

Impact of Intraoperative Anesthetic and Fluid Management on 30-day Postoperative Outcomes in a Newly Established Surgical Peritoneal Surface Malignancy Program

Background: Anesthetic and fluid management during cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) may influence 30-day postoperative outcomes. We investigated intraoperative management differences and their relation to outcomes in all consecutive patients undergoing HIPEC and CRS following the first 2 years after initiation of this surgical oncology program in a single center. Methods: Following IRB approval we retrospectively recorded demographics, intraoperative anesthetic and fluid management and 30-day postoperative cardiopulmonary, renal, infectious, neurologic, and surgical complications, mortality and length-of-stay in patients undergoing CRS and HIPEC. The Chi-square, Fisher’s exact and Wilcoxon two-sample tests were used for statistics. A p < 0.05 was significant. Results: We identified 34 patients with a mean age of 53.9 ± 11.5 years. Postoperative complications occurred in 14 patients (41%), twelve of whom (35%) had pulmonary adverse events. Patients with complications were significantly older (p=0.04) and were significantly longer hospitalized (p=0.00). Neither primary malignancy type nor intraoperative fluid replacement differed between groups. Patients with complications had mild preoperative anemia (p=0.052).

Evolution of locoregional treatment for peritoneal carcinomatosis: single-center experience of 308 procedures of cytoreductive surgery and perioperative intraperitoneal chemotherapy

Background Peritoneal carcinomatosis imposes an enormous clinical burden to the oncologic community. This study reports the patterns of care of the locoregional approach of cytoreductive surgery (CRS) and perioperative intraperitoneal chemotherapy as a curative procedure for peritoneal carcinomatosis from the experience of a single tertiary center in Australia. Methods We performed a review of clinical records from a prospective database of patients who were treated at the St George Hospital Peritoneal Surface Malignancy Program according to a standard protocol. Results A total of 308 CRS were performed in 249 patients with peritoneal surface malignancy; the mean age was 53 years and 55% were women. Over the years, we expanded the age limit for treatment ( P = .03), reduced intensive care unit stays ( P = .04), reduced amount of blood transfusion ( P = .03), treated patients with a higher peritoneal cancer index ( P < .001), achieved higher rates of complete cytoreduction ( P = .003), increased use of PIC ( P < .001), and improved complication rate ( P = .02) and mortality rate ( P = .01). The median survival of patients treated over the years also improved ( P = .001). Conclusions We show the maturity of the treatment of peritoneal carcinomatosis with CRS and perioperative intraperitoneal chemotherapy in our institution after an initial learning curve with expansion of the selection criteria, improved perioperative outcomes, improved surgical results, and long-term survival outcomes.

Evaluation of the Cost-Effectiveness of Cytoreductive Surgery and Hyperthermic Intraperitoneal Chemotherapy (Peritonectomy) at the St George Hospital Peritoneal Surface Malignancy Program

Cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) are treatment approaches for peritoneal carcinomatosis that has demonstrated improved survival outcomes with acceptable complication rates. This report aims to measure and describe the survival outcomes and health care cost associated with CRS and HIPEC for peritoneal surface malignancies at a centralized tertiary institution in Australia. The expenditure of treatment for 136 consecutive patients who underwent 159 CRS and HIPEC from June 2002 to June 2008 were obtained. Together with their survival outcomes from treatment, a cost-effectiveness analysis was performed. The average cost of CRS and HIPEC per patient and per life year for appendix cancer is AUD $88,423 (range, AUD $23,933-AUD $299,145) and AUD $37,737/LY; for colorectal cancer is AUD $66,148 (range, AUD $26,079-AUD $409,666) and AUD $29,757/LY; for pseudomyxoma peritonei is AUD $92,308 (range, AUD $11,562-AUD $501,144) and AUD $29,559/LY; for peritoneal mesothelioma is AUD $55,062 (range, AUD $23,261-AUD $94,104) and AUD $20,521/LY; and for other peritoneal surface malignancies is AUD $44,668 (range, AUD $31,592-AUD $70,026) and AUD $22,091/LY. This complex surgical treatment results in significant increases in medical costs with a parallel increase in survival for a disease that has been poorly treated, and hence may be considered as cost-effective given the observed life years gained.

The St George Hospital Peritoneal Surface Malignancy Program - where are we now?

The St George Hospital Peritoneal Surface Malignancy Program - where are we now?