ASO Author Reflections - Opportunity to Improve Outcomes in Patients with Gastric Cancer

Q: Why is staging laparoscopy with peritoneal cytology important in gastric cancer?

Occult peritoneal metastasis is found in a substantial fraction of newly diagnosed patients, so staging laparoscopy with cytology supports accurate staging and appropriate treatment planning.

Q: What compliance issue is highlighted before neoadjuvant systemic therapy?

Compliance with staging laparoscopy prior to neoadjuvant systemic therapy is reported as only 30%, and peritoneal metastasis incidence among those who underwent staging was as high as 38%.

Q: What approaches are proposed to improve outcomes?

The authors propose education and community outreach, stronger multidisciplinary involvement from surgeons early in care, removal of insurance/access barriers, and an AI deep-learning model to objectively assess peritoneal metastasis risk using CT scans and clinical factors.

Sep 29, 2026

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Gastric cancer peritoneal metastasis carries extremely poor survival, and occult peritoneal disease is present in 30–40% of newly diagnosed cases, making staging laparoscopy with peritoneal cytology critical. Reported compliance with staging laparoscopy prior to neoadjuvant systemic therapy is only 30%, with high peritoneal metastasis detection when staging is performed. Understaging may delay appropriate first-line therapy and clinical trial access. The authors call for education, multidisciplinary care, barrier reduction, and AI deep-learning risk assessment using imaging and clinical factors.

LanguageEnglish

CategoryHealthcare

FormatPDF

Pages2

Reading Time5 min

AccessFree to download

Background and clinical rationale

Compliance gap and clinical consequences

Barriers and improvement strategies

Education and multidisciplinary care

AI deep-learning risk assessment

Looking forward

Ann Surg Oncol (2026) 33:1435–1436 [https://doi.org/10.1245/s10434-025-18689-5](https://doi.org/10.1245/s10434-025-18689-5) ASO AUTHOR REFLECTIONS ASO Author Reflections: Opportunity to Improve Outcomesin Patients with Gastric Cancer Arsha Ostowari, MD1, and Maheswari Senthil, MD, FACS2 1Department of Surgery, University of California, Irvine Medical Center, Orange, CA; 2Division of Surgical Oncology, Department of Surgery, University of California, Irvine Medical Center, Orange, CA Gastric cancer peritoneal metastasis is associated with extremely poor survival. 1 Unfortunately, radiographically occult peritoneal metastasis is present in 30-40% of newly diagnosed gastric cancer cases.2–4 Therefore, staging laparoscopy (SL) with peritoneal cytology is considered a critical component of the staging workup and the National Comprehensive Cancer Network strongly recommends SL with cytology for adequate staging of gastric cancer.5 Regrettably, we found that the compliance with SL prior to neoadjuvant systemic therapy (NST) in patients that were referred/treated at our tertiary academic institutions was only 30% .6 The poor compliance with SL is even more worrisome as the incidence of peritoneal metastasis in patients who underwent SL was as high as 38% . Not surprisingly, in the patients in whom SL was omitted prior to NST, the median time to recurrence after gastrectomy was 11 months and the most common site of recurrence was the peritoneum. These results raise serious concerns about the management approach of patients with newly diagnosed gastric cancer particularly in the context of increasing incidence of gastric cancer in the United States. Surveillance, epidemiology and end results (SEER) data show that since 2019 the annual percentage incidence of new gastric cancer cases has been increasing by 3.6% in both sexes combined, and by 6.2% This article refers to: Ostowari A, Chen KT, Hasjim BJ, et al. Underutilization of Staging Laparoscopy Prior to Neoadjuvant Systemic Therapy in Gastric Cancer. Ann Surg Oncol. 2025.([https://doi.org/10.1245/s10434-025-18547-4](https://doi.org/10.1245/s10434-025-18547-4)). © The Author(s) 2025 First Received: 21 October 2025 Accepted: 22 October 2025 Published online: 11 November 2025 M. Senthil, MD, FACS [e-mail: maheswas@hs.uci.edu](e-mail: maheswas@hs.uci.edu) in females alone. Even more alarming is that the highest percentage change in increasing incidence (4.3%) is seen in people < 50 years of age.7 These trends are worrisome and further amplify the issue about inadequate staging and treatment in the youngest group of patients in whom there is a tremendous impact with missed opportunity for meaningful extension of life. While the reasons for poor compliance with SL are difficult to determine, it is likely multifactorial and possibly influenced by institutional and provider practice preferences, insurance barriers, access issues, and the sense of urgency to start systemic therapy. Nevertheless, the importance of identification of metastatic disease and formulating a treatment plan that is stage appropriate cannot be overemphasized. In the past decade, treatment of gastric cancer, particularly metastatic gastric cancer has evolved with the addition of immune checkpoint inhibitors and targeted therapies, and these combinatorial approaches are associated with improved overall survival.8,9 Furthermore, the utilization of regional therapies in combination with systemic therapy through clinical trials are also options for these patients. For example, in the United States, EA2234 STOPGAP II (NCT 07001748) is a randomized controlled clinical trial evaluating the role of intraperitoneal paclitaxel combined with systemic therapy in patients with synchronous gastric cancer peritoneal metastasis (CYT+ or peritoneal carcinomatosis) .10 Hence, regardless of the reasons behind the poor compliance, under staging patients would deprive them from receiving the appropriate first

FAQs

Why is staging laparoscopy with peritoneal cytology important in gastric cancer?

Occult peritoneal metastasis is found in a substantial fraction of newly diagnosed patients, so staging laparoscopy with cytology supports accurate staging and appropriate treatment planning.

What compliance issue is highlighted before neoadjuvant systemic therapy?

Compliance with staging laparoscopy prior to neoadjuvant systemic therapy is reported as only 30%, and peritoneal metastasis incidence among those who underwent staging was as high as 38%.

What approaches are proposed to improve outcomes?

The authors propose education and community outreach, stronger multidisciplinary involvement from surgeons early in care, removal of insurance/access barriers, and an AI deep-learning model to objectively assess peritoneal metastasis risk using CT scans and clinical factors.

Sep 29, 2026

Upload by Ivy