TABLE 2 |.

The seven pillars of ecosystem management translated to oncology

Pillar	Application to the management of microbiota in patients with cancer
Ecosystem management reflects a stage in the evolution of social values and priorities	Managing microbiota in patients with cancer reflects a broader shift in medical priorities, which emphasize precision medicine, patient-centred care and public health. These approaches seek to balance individual treatment outcomes with public health goals, such as antibiotic stewardship and control of infections in oncology wards.
Ecosystem management is place-based, and the boundaries of the place must be clearly and formally defined	Effective microbiota management in patients with cancer is patient-specific, focusing on the individual’s unique microbiota composition and their health status. In gut-associated cancers and in patients with cancer receiving immune checkpoint inhibitors, the primary ‘place’ is the intestinal microbiota, which directly affects cancer progression and response to systemic treatment. The oral, lung, skin, or vaginal microbiota might also have important roles in other cancers. Defining the appropriate ‘place’ for microbiota management should consider local and systemic effects30.
Ecosystem management should achieve the desired benefits	The goal of microbial management in oncology is to optimize microbial functions to support the effects of treatments for cancer and overall health. These approaches can include interventions such as supplementation with defined mixtures of probiotic microbes, dietary modifications to enhance microbiota resilience and function, and rational administration of prophylactic antibiotics in patients with cancer.
Ecosystem management can exploit the ability of ecosystems to respond to natural and artificial stressors	The resilience of microbiota to cancer treatments and other interventions must be leveraged while recognizing its limits. Strategies should minimize collateral damage from chemotherapy and antibiotics, and support microbial recovery and stability.
Ecosystem management might not necessarily result in an emphasis on biological diversity	High microbial diversity in the intestine is often associated with superior outcomes and loss of diversity is linked to inferior outcomes15, although in some contexts (such as vaginal cancer) higher diversity can be detrimental35. In many cases, the emphasis should be on preserving specific taxa (such as Faecalibacterium and Akkermansia in patients undergoing allogeneic haematopoietic stem cell transplantation)9 rather than on maintaining overall diversity.
The sustainability of interventions should be clearly defined	The benefits from cancer treatments, such as high efficacy and low toxicity, must be weighed against potential disadvantages, including the risk of disrupting the microbiota and long-term effects in overall health.
Scientific information is crucial, but is only one element in a decision-making process of public or private choice	Collaborative decision-making involving health-care providers, patients and their carers is essential to tailor microbiota management strategies to each patient’s needs and values.

Ecosystem management has seven pillars¹¹. The integration of these principles in the routine management of the microbiota in patients with cancer can result in precision approaches that improve patient outcomes.