NCCN Guidelines on Hernia Management in Cancer Patients
The NCCN guidelines address hernias primarily in the context of malignant bowel obstruction and palliative care, recommending assessment of internal hernias as a reversible cause of obstruction, with treatment decisions guided by prognosis and goals of care rather than providing comprehensive hernia repair protocols.
Hernia Assessment in Cancer Patients
When to Screen for Hernias
The NCCN Palliative Care guidelines recommend screening for internal hernias specifically when evaluating malignant bowel obstruction 1. This assessment should occur:
- In patients with years of estimated life expectancy: Screen for and treat underlying reversible causes including adhesions, radiation-induced strictures, and internal hernias 1
- During obstruction workup: Internal hernias should be assessed alongside tumor mass and carcinomatosis as potential causes of obstruction 1
Prognostic Stratification
The guidelines stratify management recommendations by estimated life expectancy 1:
- Years to months: Consider medical management rather than surgical management 1
- Months to weeks: Medical management is preferred over surgical intervention 1
- Assessment of treatment goals should guide intervention decisions (e.g., decrease nausea/vomiting, allow patient to eat, decrease pain, allow patient to go home/hospice) 1
Management Approach
Operative Management Considerations
When surgery is considered, the NCCN emphasizes that improved quality of life should be the primary goal of surgical treatment 1. Key considerations include:
- Risks must be discussed with patient and family, including mortality, morbidity, and reobstruction 1
- Operative management is listed as an intervention option for internal hernias causing obstruction 1
- Surgical expertise and resources should influence the decision-making process 1
Alternative Management Options
For patients where surgery is not appropriate, the guidelines recommend 1:
- Endoscopic management: Percutaneous endoscopic gastrostomy tube for drainage or endoscopic stent placement 1
- Interventional radiology: Ultrasound-guided gastrostomy tube for drainage 1
- Pharmacologic management: When gut function cannot be maintained, use anticholinergics (scopolamine, hyoscyamine, glycopyrrolate) and octreotide 1
Critical Decision-Making Framework
Goals of Care Assessment
The assessment of treatment goals for the patient should guide the intervention 1. Specific goals to consider include:
- Decrease nausea and vomiting 1
- Allow patient to eat 1
- Decrease pain 1
- Allow patient to go home or to hospice 1
Education and Support
- Provide education and support to patient and family when considering management options 1
- Ensure interventions are consistent with the goals of care 1
Important Caveats
The NCCN guidelines do not provide comprehensive hernia repair protocols for cancer patients. Instead, they address hernias specifically in the context of:
- Malignant bowel obstruction as a palliative care issue 1
- Internal hernias as a reversible cause requiring assessment 1
- Surgical decision-making based on prognosis and quality of life goals 1
For symptomatic hernias in cancer patients without obstruction, the guidelines do not provide specific recommendations. In these cases, standard hernia management principles would apply, with consideration of the patient's overall cancer prognosis, performance status, and treatment goals 1.
Multidisciplinary evaluation is essential, as all cancer patients should be evaluated and managed by teams with expertise in their specific condition 1.