International practice patterns and perceptions of pressurised intraperitoneal aerosol chemotherapy for management of gastric cancer: A global clinician survey

BACKGROUND: Gastric cancer with peritoneal metastases remains a major clinical challenge, with poor prognosis and limited benefit from systemic therapy. PIPAC is an emerging locoregional option used mainly in the palliative setting, however international practice remains heterogenous, particularly with respect to patient selection, chemotherapy regimens, and response assessment. This study aimed to capture international practice patterns and identify areas of consistency, variation and evidence gaps in the use of PIPAC for gastric cancer. METHODS: A 44-question online survey was distributed electronically via the International Society for the Study of Pleura and Peritoneum (ISSPP) and directly to expert clinicians involved in the use of PIPAC for gastric cancer management. The survey examined clinician and centre-level practices pertaining to patient selection, intraperitoneal chemotherapy protocols and perceived utility and limitations of this approach in managing gastric cancer. RESULTS: Complete responses were obtained from 80 clinicians representing 62 centres across 28 countries. Marked international variability was observed in patient selection, treatment intent, and response assessment. However, several areas of consistencies were identified, including predominant use of cisplatin/doxorubicin-based regimens, similar procedural approaches, and reliance on intraoperative, radiological, and pathological regression grading to assess treatment response. Lack of high-quality prospective evidence was consistently identified as the principal barrier to broader adoption and standardisation. CONCLUSION: This international survey provides comprehensive insight into clinician decision making in the use of PIPAC for gastric cancer. The findings demonstrate heterogeneity and emerging areas of practice convergence, and may inform pathway development, priorities for prospective research and future standardisation efforts.