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Interviewer: For patients with certain advanced abdominal cancers, surgical removal of the cancerous tissue is a common treatment, but there is an additional procedure that could improve a patient's chance for success. It's called HIPEC, and the procedure delivers heated chemotherapy directly into the abdomen.

Surgical oncologist Dr. Erin Ward joins us from Huntsman Cancer Institute. She specializes in the treatment of abdominal cancers, and today, she's going to help us better understand when HIPEC is used, why it's used, and how recent advances have made it available to patients who in the past weren't eligible for HIPEC treatment.

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) as Targeted Treatment for Advanced GI Cancers

Dr. Ward: So HIPEC stands for heated intraperitoneal chemotherapy.

Interviewer: All right. And who is HIPEC surgery for? Which is what it's commonly called, right, HIPEC?

Dr. Ward: HIPEC surgery, also known as cytoreductive surgery plus HIPEC, is for patients with advanced GI cancers that have spread to the peritoneum or outside of the primary organ. It is for a variety of diseases, but the most common ones that we treat are appendix, colorectal cancer, gastric cancer, as well as mesothelioma.

Interviewer: All right. And I see that there are some other cancers that it can be used for, but you didn't mention them right there. Why is that?

Dr. Ward: The other diseases that we use HIPEC for include ovarian, as well as some sarcomas, but specific types of sarcomas. The ones that I named first were kind of the most common.

Interviewer: And for a patient that has one of the cancers that you use HIPEC to treat, if they were unaware of HIPEC surgery, that that was even an option, what would their path of treatment look like? And then I want to talk about what it would look like if they were aware of what HIPEC was available.

Dr. Ward: So the treatment for all these diseases is different depending on if they have other treatment options. For appendix tumors and/or cancer, there are fewer options in terms of systemic therapy or radiation, so chemo or radiation. So, for those patients, HIPEC or cytoreductive surgery is commonly one of the only options. Other cancers like gastric cancer and colorectal cancer have other treatment regimens, like systemic chemotherapy, that can be incorporated with surgery.

Interviewer: And for the first group that you talked about where HIPEC is kind of the treatment, are there patients that aren't aware that it's an option and don't get any treatment?

Dr. Ward: There are probably some patients out there who are unaware. Luckily, we have some really good groups out there that have a big online presence that help patients with low-grade appendiceal mucinous neoplasms find centers that have high-volume HIPEC programs that can help them get those treatments.

Incorporating Hyperthermic Intraperitoneal Chemotherapy (HIPEC) into Treatment Regimens

Interviewer: And for the second group of people where this is one of the treatments that are available, is it generally a first-line treatment? Is it kind of the last-line treatment? Where does it fall in that hierarchy?

Dr. Ward: So for colorectal cancer, it is more commonly used when patients only have a disease that is spread to their peritoneum but hasn't gone to the liver or the lungs.

It's often incorporated as part of a multidisciplinary treatment plan. So we work with the medical oncologist, and the radiation oncologist, to figure out how we can incorporate cytoreduction surgery and HIPEC in a way that's going to be meaningful to that patient.

Interviewer: So it's not necessarily always a standalone treatment. It's part of a group of treatments that you would try to use to take care of the disease in any particular individual situation.

Dr. Ward: Exactly. Yep.

The Hyperthermic Intraperitoneal Chemotherapy (HIPEC) Surgical Process

Interviewer: All right. And then tell me how the surgery is performed.

Dr. Ward: So the goal of the surgery is to remove all the disease we can see, and then this can involve a bunch of different procedures. It can be as simple as removing the appendix and a couple of other things, or as extensive as multiple organs being removed.

But after we establish whether or not we've been able to remove all the disease, we then proceed with the heated intraperitoneal chemotherapy. There are a couple of ways to approach this, but most large institutions are doing this as part of the cytoreductive surgery. So we actually temporarily close and infuse the heated chemo during the same surgery, then remove the heated chemotherapy, irrigate, and then close again, and that's the end of the surgery.

Role of Heat in Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Interviewer: What is it about heating the chemotherapy? What does that accomplish that if you didn't heat it, you would not be able to do?

Dr. Ward: There are some places that don't necessarily do heated chemotherapy, but the thought behind the heating is that we can maybe improve the ability of that chemotherapy to get deeper in the tissue as well as use the body's improved tolerance of heat compared to the cancer cells, potentially leading to some more cancer cells dying just from being heated up.

Interviewer: And how often does a patient need to come back for HIPEC treatments? Or does it tend to be just when they have the surgery where they're removing the cancerous material, that's the only time, or are there follow-ups?

Dr. Ward: So typically, once we've completed the cytoreductive surgery and the HIPEC, that's done for that patient. So they're not continuously getting chemotherapy after the surgery. There are some unique situations where patients with gastric cancer in particular may get some repeat HIPEC surgeries, often in a laparoscopic fashion.

Pre-Surgery: Preparing for Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Interviewer: And what is the preparation process like for a patient before a surgery like this? What does that look like?

Dr. Ward: So before any big surgery, we try to make sure the patient is all set up to be successful after surgery. So that involves making sure they've got all the social support in place, that they've completed all the other treatments that they need to complete.

But we also work with their medical doctors to make sure that their other health is optimized. So that may involve going to a cardiologist or starting an exercise program. But the goal is to get them ready to be successful and rapidly recovering from the surgery.

Post-Surgery: Follow-Up, Repeat Treatments, and Recovery

Interviewer: And what does that recovery process look like? I understand after the surgery, the care has improved a lot in the past 10 years.

Dr. Ward: Yeah, I would say overall our ability to take care of patients who have undergone big surgeries has improved a lot over the last 10 years, and this also pertains to patients after HIPEC.

So after one of these surgeries, most of the time patients stay in the hospital anywhere from 5 to 10 days. Typically, I tell people about 7 to 10.

And then after surgery, when you go home, it can take a couple of months to really feel back to normal, but it's not like you're bedridden or anything like that. Actually, we want you to continue to be active with your family. Walk every day. You're back to a regular diet. And honestly, most patients go home on just Tylenol and ibuprofen by the time they're done with their hospital stay.

Interviewer: And after they go home, if a patient has a job that doesn't require physical labor, are they able to go back to work relatively quickly, or . . .

Dr. Ward: Yeah. So I always talk to the patients about what they do at work, and we try to incorporate that in terms of when they can go back to work. So patients who work at a computer at home, sometimes they'll want to go back as soon as two weeks, but often I say it's better to ask for more time off and go back early rather than have to ask for more time. I think the soonest I've had somebody go back to a desk job is about two to three weeks.

Interviewer: Okay. And then if you are more physical labor, what does that process of going back to work look like?

Dr. Ward: There are a couple of things you need to have checked off before you can go back to physical labor. One, we want you at least six weeks out from surgery before you're lifting anything heavier than 10 pounds, and that's really to protect your incision. And also you need to be off narcotic medications or anything else that would inhibit your ability to make quick decisions.

Managing Hyperthermic Intraperitoneal Chemotherapy (HIPEC) Side Effects

Interviewer: And what about other types of side effects that people might encounter? Pain? It doesn't sound like pain is too much of an issue. You mentioned that a lot of times patients just go home with Tylenol.

Dr. Ward: Yeah, so just like we've improved our ability to take care of surgical patients, we've also improved our ability to treat pain in the post-op period.

So, after surgery, we often use a local anesthetic that is constantly infused in the wound to try to take the edge off, and then we use multiple types of pain control, including narcotics, Tylenol, NSAIDs like ibuprofen, as well as other ones to try to take that edge off.

And usually, by the time patients go home 7 to 10 days later, again, they're mostly on Tylenol or ibuprofen.

Interviewer: What about other side effects, like typical chemotherapy-type side effects like hair loss? Does this procedure cause that?

Dr. Ward: No patients I've ever taken care of have had hair loss from this kind of chemotherapy. Most of the time, people just feel a little bit more tired than just a regular surgery. So the first couple of days, you may feel a little bit more tired than if you had just the surgery without the HIPEC. But there are not any systemic consequences of hair loss.

Life After Hyperthermic Intraperitoneal Chemotherapy (HIPEC)

Interviewer: And then life after treatment, what are the outcomes generally? Are you working for quality of life, survival, or both?

Dr. Ward: The answer is really both. It depends on that unique patient. For some tumors or cancers where there are limited other options, sometimes we do palliative HIPEC procedures. But for a lot of the patients, the goal is long-term survival, particularly for patients with appendiceal neoplasms where we know patients can get up to 10 years. And for other diseases, we know that we can improve their long-term survival if we can reduce their tumor burden.

Interviewer: So then what's next after that? After the procedure, are you continually going back to your doctor for imaging and other treatments, or what does that look like?

Dr. Ward: Yeah, so depending on the type of tumor we're treating, some patients will need additional systemic chemotherapy. But patients who don't need other systemic therapy, still need frequent surveillance, meaning they still come back to see me and their medical oncologist. Usually every six months for the first couple of years for CT scans, and then we usually spread them out to about once a year. And for some of these tumors, because we know it's so effective, we actually follow patients for up to 10 years to make sure we don't miss a recurrence.

Interviewer: How widely known is HIPEC surgery among referring physicians?

Dr. Ward: I think it's well-known for certain diagnoses. So for patients with LAMNs or HAMNs where that really is the only treatment option, it is well established and well known.

I think this is a rapidly evolving field where more diseases are becoming candidates for this kind of treatment, and part of that is because we're doing such a good job of evolving our options for systemic therapies.

So as more patients are living longer, it's nice to have an aggressive local treatment for those patients who only have disease in their belly but not in their lungs or liver. And the only reason that we have more of those patients is because we've improved our systemic therapy.

Seeking Hyperthermic Intraperitoneal Chemotherapy (HIPEC) Treatment

Interviewer: If a person is wondering if they're a good candidate, can they make an appointment directly with a HIPEC specialist, or do they need a referral? How would that work?

Dr. Ward: Most of the time, patients need a referral, but most of us are open to referrals from primary care physicians or medical oncologists. Sometimes it depends on your insurance, but the majority of us who are treating this know that it's hard to find us and are happy to see you.

Interviewer: And just one more thing that I'm curious about. I've heard that patients who couldn't get HIPEC treatment before might be able to get it now. So what has changed?

Dr. Ward: For patients who aren't necessarily offered cytoreductive surgery and HIPEC in the beginning, as our systemic treatments are improving and the other sites of disease may go away or improve, patients who may not have been good candidates to begin with may become better candidates later.

So just because you may not be a good candidate for this kind of surgery now doesn't mean it's always going to be off the table.