Personalized treatment selection in colorectal cancer with peritoneal metastasis: Do we need statistically validated indicators or cultural shift?

The study by Wu et al analyzed the correlation between nutritional and inflammatory markers and prognosis in patients with colorectal cancer peritoneal metastasis. The authors propose the neutrophil-to-lymphocyte ratio (NLR) as a predictor of overall survival (OS) and developed a nomogram incorporating NLR, hemoglobin (Hb), and peritoneal cancer index (PCI) to estimate 1- and 2-year survival. Although the nomogram shows high accuracy, the group of patients analyzed is heterogeneous with respect to the surgical treatment received, and no clear definitions are given for normal Hb and there is no reason for choosing a very high PCI (>= 20). Patient selection for cytoreductive surgery with hyperthermic intraperitoneal chemotherapy requires a multidisciplinary approach. Over-simplification of the selection pathway may deny access to curative treatments to patients who could benefit. While methodologically sound, the study does not consider the effect of treatment received on OS, thus introducing a potential bias.