Chemo Bath Heats Up Debate About Radical Treatments for Rare Cancers

Treatment sparks heated debate about risk-benefit balance.

Aug. 15, 2011— -- Kitty Kane went in for routine surgery to remove fibroids from her uterus. But through the tiny bikini-line incision, her surgeon discovered a tumor on her appendix slowly spewing what looked like marmalade throughout her abdomen.

After cutting out the tumor, he hurriedly washed away the thick jelly -- a mixture of mucous and cancer cells -- from 40 pounds of intestines pulled up through the small opening near Kane's pelvis. When Kane awoke, she couldn't believe her ears.

"They told me the tumor was gone, but there was still this coating," said Kane, who lives in Spokane, Wash.

A single cancerous cell in that jelly coating could attach to any organ and divide to form a secondary tumor, called a metastasis. But until that happened, doctors told her, there was nothing they could do.

"I said, 'What? We're just going to leave it?'" Kane said. "No, I'm the type who needs to do something."

Desperate for another option, Kane scoured the Internet until she came across Hyperthermic Intraperitoneal Chemoperfusion, or "Hipec" -- a procedure that would have her abdomen split open from sternum to pelvis, filled with hot chemotherapy and swished around like a water balloon to coax cancer-killing medicine into every nook and cranny.

"It was over-the-top weird," Kane said. "I was scared, but at the same time it didn't seem like there were any other options. Either you do nothing and start cutting out parts later on, or you think, 'Let's be proactive and see if it works.'"

But the treatment continues to draw criticism from doctors who say its effectiveness is far from proven. Because metastatic cancers of the abdomen are relatively rare, large clinical trials are difficult to execute, limiting evidence of Hipec's success to smaller studies and personal anecdotes.

"Drug development undergoes decades of scrutiny at the cost of millions," said Dr. Joel Levine, founding director of University of Connecticut Health Center's Colon Cancer Prevention Program in Farmington, Conn. "Devices have to proved safety though the market place remains the test for efficacy. Here, a very invasive and potential lethal therapy is made available to those who can afford the incremental cost of the 'hot bath' with insurance generally absorbing the expenses associated with the operation."

In Kane's case, the procedure lasted seven hours, during which her surgical oncologist removed her uterus, ovaries and six inches of intestine determined to be prime seeding grounds for new tumors.

"Ovaries look like chewed gum," her doctor said, explaining that they're full of hiding places.

For two hours, hot chemotherapy filled the newly emptied cavity. Then Kane was stapled back together. And through two catheters, toxic drugs pumped in and out of her bloated belly for six more days.

"My goal was not to think I had cancer anymore," Kane said. "I wanted to do everything I could."

Now, five years later, she's cancer-free.

Heated Debate Over Hot Chemo Bath

In the 30 or so years since Hipec was first introduced, more and more hospitals have begun to offer it. Supporters say it can even help prevent metastases from colorectal and ovarian tumors.

"I think this should be the standard of care for four or five different conditions where cancer has a propensity for causing peritoneal metastases," said Dr. Paul Sugarbaker, a surgeon at Washington Hospital Center in Washington, D.C., and a leading Hipec proponent.

But Hipec is invasive and risky. The combination of radical surgery and toxic chemotherapy that makes it effective, proponents say, also makes it dangerous. But doctors who use Hipec are quick to point out the dangers of traditional intravenous chemotherapy, including a heightened infection risk and the possibility of nerve damage.

"Systemic chemotherapy is incredibly toxic," said Dr. Steve Libutti, director of the Montefiore Einstein Center for Cancer Care in New York City. "Ask anyone who's ever had it; it's no walk in the park."

What worries skeptics is the risk-benefit ratio. In the long run, only one in three Hipec patients stays cancer-free.

"Do we claim to cure every patient we treat? Absolutely not," Libutti said. "Do we claim to improve the possible outcome? Absolutely I think it's a great option."

More Hospitals Offering Hot Chemo Bath

Several hospitals nationwide now offer the procedure, including Manhattan's Mount Sinai Medical Center, Massachusetts General Hospital in Boston and University Hospitals Case Medical Center in Cleveland. MD Anderson Children's Cancer Hospital, at the University of Texas in Houston, offers Hipec for kids with abdominal tumors. Companies that manufacture Hipec equipment estimate that about 20,000 patients could be treated in the United States each year, Sugarbaker of Washington Hospital Center said, but fewer than 2,000 patients actually are.

In January 2010, Hipec was featured in an episode of ABC's medical drama TV series, "Grey's Anatomy."

"I totally watched that episode," Kane said. "We were like, 'That's it? That's all they said about it? It was too short, but whatever."

Kane, who just turned 46, said she would have Hipec again if her cancer came back.

"I know there are a lot of considerations -- each person is different, each situation is different," she said. "But for me, there was no alternative. And I couldn't just wait for something bad to happen."

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