March 20, 2020
By 2035, researchers predict that the incidence of ovarian cancer (OVCA), which includes cancers of the fallopian tube and peritoneal cavity, will increase by 55% and deaths will increase by 67%. Currently, OVCA is the seventh most common female cancer and eighth most common cause of death for women worldwide.
Despite aggressive treatment, the majority of patients with advanced OVCA will experience recurrence. OVCA is treated with a combination of chemotherapy and surgery. Currently, the five-year survival of stage III OVCA is 42%.
Because of these somber statistics, tactics to treat peritoneal dissemination have been a major focus of researchers. In a retrospective review published in the Indian Journal of Gynecologic Oncology in November 2019, Carrie L. Langstraat, M.D., with Obstetrics and Gynecology at Mayo Clinic in Rochester, Minnesota, and a team of Mayo Clinic providers and researchers reviewed the use of an alternative, innovative method of delivering chemotherapy.
Hyperthermic intraperitoneal chemotherapy
Hyperthermic intraperitoneal chemotherapy (HIPEC) delivers chemotherapy directly into the abdomen, making it a good option for peritoneal dissemination.
Immediately after removing visible tumors through cytoreductive surgery, surgeons pump a powerful dose of heated chemotherapy inside a patient's abdomen. The chemotherapy agent is administered directly to the peritoneal cavity while taking advantage of the cytotoxic effects of heat on cancer cells.
"HIPEC is given as a single treatment in the operating room," says Dr. Langstraat. "This technique offers the benefit of direct exposure of the peritoneum to the chemotherapeutic agent immediately after surgery, increasing the chance of equal distribution of the agent to the entire abdominal cavity."
One randomized trial has shown that HIPEC given at the time of interval cytoreductive surgery improves survival and decreases the risk of peritoneal recurrence. This study, along with many others, has shown that HIPEC can be administered safely with minimal side effects.
Despite these positive results, Dr. Langstraat says the majority of patients with advanced OVCA will still experience recurrence, most commonly in the abdomen. "HIPEC has shown to decrease that risk and improve the survival of patients with other peritoneal-based malignancies."
Additional phase III trials are needed to identify which chemotherapy drug, at which dose, should be delivered with HIPEC, Dr. Langstraat says. She has reviewed multiple studies that have shown similar results: HIPEC with cisplatin or carboplatin is overall well tolerated with grade 3 to 4 toxicity observed in 20% to 30% of patients. However, she says the ideal dose of cisplatin and carboplatin may require additional studies.
Regarding cost-effectiveness of this technique, Dr. Langstraat evaluated two studies published in Gynecologic Oncology and the Journal of Clinical Oncology, respectively, in 2019. Both of those research teams found that although interval cytoreduction with HIPEC is more costly, it is more cost-effective than interval cytoreduction alone, taking into account ostomy rates, need for second surgeries and other outcomes.
Dr. Langstraat notes there are currently 43 ongoing trials using HIPEC in OVCA; 18 are actively recruiting patients. "This demonstrates the interest in further developing this technique and shows promise that in the near future, we will have a clear understanding of the effectiveness of HIPEC in patients with OVCA."
For more information
Langstraat C. Review of the outcomes of ovarian cancer treated with cytoreductive surgery and heated intraperitoneal chemotherapy. Indian Journal of Gynecologic Oncology. 2019;17:94.
Lim SL, et al. Cost-effectiveness of hyperthermic intrapertioneal chemotherapy (HIPEC) at interval debunking of epithelial ovarian cancer following neoadjuvant chemotherapy. Gynecologic Oncology. 2019;153:376.
Koole SN, et al. Cost effectiveness of interval cytoreductive surgery with hyperthermic intraperitoneal chemotherapy in stage III ovarian cancer on the basis of a randomized phase III trial. Journal of Clinical Oncology. 2019;37:2041.