On this Mayo Clinic Q&A podcast, Dr. Travis Grotz, a Mayo Clinic surgical oncologist, explains what hyperthermic intraperitoneal chemotherapy (HIPEC) is, how it is performed, and the risks and benefits of the treatment.
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Dr. Travis Grotz: HIPEC is like
a chemical to just kind of
sterilize the microscopic stuff
the surgeon can't see. And so
that's why, combined with
surgery to remove everything
that we can see and then
chemotherapy to get rid of the
stuff we can't see, those two
together then increase our
success rate our likelihood of
the cancer not coming back.
Narrator: HIPEC or Hyperthermic
Intraperitoneal Chemotherapy is
used for many patients with
advanced abdominal cancers. It's
an alternative to traditional
chemotherapy or radiation
therapy. HIPEC is placed
directly in contact with the
tumors to kill cancer cells that
may remain after surgery. And
since this type of chemotherapy
doesn't go throughout the body,
higher doses of the drugs can be
used.
DeeDee Stiepan: Welcome everyone
to Mayo Clinic Q&A. I'm Dee Dee
Stiepan sitting in for Dr.
Halena Gazelka. HIPEC stands for
Hyperthermic Intraperitoneal
Chemotherapy. Hypothermic means
warm or hot, intraperitoneal
means inside the abdominal
cavity, which is encased in a
sac called the peritoneum. HIPEC
is used in conjunction with
cancer surgery, using high dose
chemotherapy to kill microscopic
cancer cells inside the
abdominal cavity. Heating the
chemotherapy drugs enhances the
procedure's effectiveness. When
the chemotherapy is hot, it
penetrates the tissue more
deeply increasing the number of
cancer cells it can reach. Here
with us to discuss is Dr. Travis
Grotz, a surgical oncologist at
Mayo Clinic. Welcome to the
program. Thanks so much for
joining us.
Dr. Travis Grotz: Good morning,
Dee Dee. Thanks for having me.
DeeDee Stiepan: Of course. So
what what cancers can be treated
with HIPEC and which patients
would be eligible for this?
Dr. Travis Grotz: Sure. So
HIPEC, as you said, is kind of
regional chemotherapy in the
abdomen. So really any cancer
that's just localized in the
abdomen on the surface of the
peritoneum, like you said, you
know, could be a candidate.
There are certainly some tumors
that have been well studied, and
we know for sure, based on
studies and data that works
well. So those cancers are
cancers of the colon, cancers of
the appendix, cancer to the
ovaries, cancer to the stomach,
and there's even a cancer of the
lining of the peritoneum called
mesothelioma. So those would be
the cancers I think that are
well studied and well accepted.
You know, there are always rare
tumors that we have less data
for such as cancer to the
pancreas or gallbladder or small
intestine, that we don't know
yet, if that's the right
treatment.
DeeDee Stiepan: Sounds good. Can
you explain sort of in lay terms
how exactly this works?
Dr. Travis Grotz: Sure. So the
way the way I kind of explain it
to people is that it's like if
you have a dirty, countertop or
table, you want to clean off all
the dirt and grime and stuff.
And so surgery, the surgical
part of the HIPEC is to remove
any tumor the surgeon can see.
But you know, if you want to eat
on that countertop, you want it
clean and sterile and get rid of
the bacteria. So we use
chemicals like bleach or
anti-bacterial disinfectants to
clean the countertop. So HIPEC
is like a chemical to just kind
of sterilize the microscopic
stuff the surgeon can't see. And
so that's why combined with
surgery to remove everything
that we can see, and then
chemotherapy to get rid of
stuff, we can't see, those two
together then increase our
success rate or likelihood of
the cancer not coming back.
DeeDee Stiepan: That's a great
explanation. I like that
comparison. So who can perform
HIPEC?
Dr. Travis Grotz: So you know,
HIPEC is a pretty complex
procedure. And so it takes a
there's a long learning curve
from the surgeon standpoint, the
hospital standpoint, the
anesthesia, the whole team
standpoint. So it takes
specialized training. So most
places, most surgeons who do it
are what's called surgical
oncologists, which are cancer
surgeons who are general
surgeons who have done another
two years of additional focused
training in cancer surgery. And
part of that two year time is
dedicated to HIPEC. So cancer
surgeons and then also
gynecological oncologists are
also, for ovarian cancer, also
are specialized in HIPEC.
DeeDee Stiepan: Very good. And
what can patients expect to
experience during a HIPEC
procedure?
Dr. Travis Grotz: Sure, I think
this is probably one of the
hardest questions to answer
because it's very variable
depending upon the surgery
component of it. So some
patients may have lots of tumor
and may need a more extensive
surgery component of it. And so
obviously, the more extensive
the surgery will be, the longer
the recovery, and can be you
know, higher risk of
complications and things like
that. And some people have very
little tumor in their abdomen
and so the surgery can actually
be very minimal. And so those
patients may recover much
quicker. And then sometimes we
even do the HIPEC alone without
surgery. And so that, you know,
obviously would have a different
recovery. But in general, I
would say, the chemotherapy,
what it adds to or HIPEC, what
it adds to the surgery is
probably, you know, some
fatigue. I think I always warn
patients, it's going to take
several months for them to get
their stamina level up, it just
kind of wears people out. I
think there's also a component,
you know, your bowels are bathed
in chemotherapy. So there's some
irritable bowel kind of symptoms
that people can experience like
gassy abdominal cramping, you
know, intermittent nausea or
diarrhea. It's generally mild,
and again, resolves over a few
months, but it's something that
people can experience. And then
in general there's less side
effects than giving it through
the vein. And that's, that's the
whole reason why we do the HIPEC
is because less of it's been
absorbed. So there's less side
effects, in general.
DeeDee Stiepan: What are the
risks of this procedure?
Dr. Travis Grotz: Sure, so you
know, the risks of HIPEC, again,
just the HIPEC portion, you
know, the chemo, again, is
usually not as much of it as
absorb, but some can be. And so
some, some chemotherapy drugs we
use, depending on the type of
cancer, can be hard on the
kidneys. And so there's certain
things that we do to decrease
that risk. And usually, using
those parameters, or those extra
steps, minimizes that risk.
Again, the fatigue, we talked
about, the irritable bowels we
talked about. It can drop your
counts, again, usually like your
white cell counts and things
like that. Usually, that's mild
and not, you know, really a
problem. But another thing to
watch out for, after surgery or
after HIPEC.
DeeDee Stiepan: And what are we
talking what kind of success
rate does this HIPEC procedure
have?
Dr. Travis Grotz: Sure, so
that's, you know, it's very
variable again, and it depends
on two things really. I think
the two most important. One is
the ability of the surgeon to
get all the tumor out. And so
when surgeons are evaluating
patients if they're candidates,
they have to be confident they
can remove all the tumor. And so
that's a critical step is being
able to remove all the tumor, in
terms of success. And then
second part is the type of
tumor. So some tumors are slower
growing, and are maybe more
sensitive to chemotherapy and
are also less invasive, meaning
less sticky, so we can peel them
off pretty easy. And so those
tumors like, the classic
Pseudomyxoma Peritonei, which is
jelly belly is another name for
that, where it's a tumor of the
appendix, it's very mucinous, a
lot of jelly. Those tumors, you
know, the survival, long term
survival can be quite high 60,
70%. So that success rates very
high. In some tumors, very
aggressive tumors, like stomach
cancer, colon cancer, you know,
the success rate might be lower
long-term success rate, you
know, more in that kind of 25 to
35, 40% range. So, that's kind
of long term success, short term
success, I think of as, too, as
an important, too. I think, you
know, chemotherapy is no fun.
And so the surgery, oftentimes,
even if we're not successful in
the long term, can extend
people's survival in the short
term, and provide time off of
therapy, where people don't have
any cancer, they're not getting
any treatment. And that
timeframe is, you know, variable
again, but at least, usually on
average, provides some time a
year and a half or two years of
time without any cancer
recurrence, and off of therapy.
So that can be a short-term
benefit as well.
DeeDee Stiepan: Very good. You
talked a little bit about what
recovery is like for patients
kind of depends a little bit, is
there anything else that people
should know about recovery?
Dr. Travis Grotz: Yeah, I mean,
I think, it might be helpful to
talk to other patients who have
gone through it, and there's a
lot of online websites and other
patients, and there are podcasts
like this and other webinars
that kind of explain it. But
again, everybody's individual,
so it's hard to take too much
from each person's experience.
But I think, again, people just
need to know that it is a big
surgery, and there's, you know,
they'll need some help at home
and some recovery. And I think
one of the hard things people
struggle with is that general,
several month period of, again,
the fatigue and not feeling the
greatest and I think it kind of
leads to some depression. I
think it's hard to feel kind of
blah for a couple of months. And
so, I think getting that support
from your family and friends and
recognizing that and trying to
find joy in life and things
around you and what you can do
is helpful. And so I think
that's something we try to help
patients with recovery point to.
DeeDee Stiepan: Absolutely.
That's so important. What are
some questions patients should
ask their health care
professionals about HIPEC, when
they're, you know, when they're
at these appointments?
Dr. Travis Grotz: Yeah, I mean,
hopefully they're getting a good
explanation like this about what
to expect about the surgery. You
know, there's the surgery side
of the HIPEC, there are,
surgeons who can do laparoscopy,
which is minimally invasive
surgery, where they stick a
camera in and take a look around
to see where the cancer is we
can get scans like CT scans,
MRIs. So we can get a good idea
of how extensive surgery would
be. But there's always a little
bit of unknown, which I think is
sometimes hard for patients.
Because at the end of the day,
our goal is to get all the tumor
out. And so there might be, when
we get in there, we might see
tumor we didn't see before on
the laparoscopy or the CT scan.
And, and so surgery can
sometimes change in the
operating room. Again, the goal
is to get all that cancer out
and, you know, obviously have
good outcome in terms of quality
of life and recovery. And so
that's a fine balance, that's
always, you know, what the
surgeons trying to strive to
get. So I think, they need to
learn from the surgeon, what
they anticipate the surgery
would look like, and how
extensive it would be. But they
have to recognize there's going
to be some flexibility. I think,
again, it's a very complex
surgery. So I think, it is one
of those ones where there's a
direct volume to outcome
relationship in terms of how
patients do. And, most
surgeries, you know, you do 20
or 30 of them, and you've kind
of gotten over the learning
curve, and surgeons are
competent and comfortable with
it. But this surgery, actually,
the research suggests it's
closer to 120, 150 procedures
before the outcomes are really
ideal. And so I think it's
important, not just from the
surgeon standpoint, but the
whole institution and having the
whole process of medical
oncologist and their involvement
and chemotherapy. And having the
nutritionists and the nurses and
the anesthesiologists and the
whole multidisciplinary team I
think is really important. So
those are things to ask about, I
guess.
DeeDee Stiepan: Absolutely.
Yeah, that's very interesting.
Is HIPEC available at all cancer
centers? And is it covered by
insurance?
Dr. Travis Grotz: Good
questions. So like I said,
again, it is somewhat
regionalized, just given the
complexity of it. So not
available, probably every cancer
center, but it is available at
most, or a lot of cancer
centers. There are, you know,
several that are very high
volume, and there's many that do
a fair amount. As far as
insurance coverage, that's
always a tough one because it's
every insurance is different.
But again, I think the ones I
just mentioned before, colon,
appendix, stomach and ovarian
cancer, there's very good data,
you know, high level data
research trials, that suggests
that there's a significant
benefit to the HIPEC portion of
the procedure. And so those in
general are covered by insurance
companies. The other ones where
we have less data for those are
a little bit tougher, just
because they're either less
common or less well studied. And
so those are a little harder
sometimes to get insurance to
cover.
DeeDee Stiepan: Good to know.
Our thanks to Dr. Travis Grotz,
a surgical oncologist at Mayo
Clinic, for being with us today.
Thanks for the great
conversation.
Dr. Travis Grotz: Thanks, Dee
Dee. Appreciate it.
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