Re: “Hot Chemotherapy Bath: Patients See Hope, Critics Hold Doubts,” by Andrew Pollack (New York Times, 8/12/11, A1):

This article about cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy (“CRS/HIPEC”) was informative and pointed out both the benefits of this treatment and some of the debate surrounding it. However, I feel that a few factual clarifications are essential to keep the dialogue about CRS/HIPEC in the proper context.

First of all, for appendix cancer (and pseudomyxoma peritonei, “PMP”) patients with mucinous tumors spreading and growing in their abdomen, being “filleted, disemboweled and then bathed in hot poison” (as awful as that sounds) is preferable to the alternative, which is almost certain death. CRS/HIPEC is the standard of care for these patients. Systemic chemotherapy alone has never been shown to be curative for this disease because of the nature of the tumors and the lack of access to them through the bloodstream. Radiation therapy is not effective against these tumors. Although surgery has long been a key component of treatment, recurrence of disease was common even when all visible disease was removed in surgery. The heated chemotherapy was added to address the microscopic cells that were the likely cause of recurrence and which were impossible to remove by even the best surgeons.

Contrary to Dr. David Ryan’s statement that cytoreductive surgery followed by hyperthermic intraperitoneal chemotherapy “has almost no basis in science,” this technique has been tried and tested in thousands of appendix cancer and PMP patients around the world and resulted in many of these patients living disease-free for upwards of 20 years – when their condition without the treatment is almost certainly fatal. Some clinical studies simply cannot be done due to lack of funding and a relatively small patient population. But in these cases studies of retrospective data can still be informative, albeit imperfect. The author cites the randomized clinical trial from the Netherlands, and numerous other studies have shown that CRS/HIPEC offers an appendix cancer patient the best chance for long term disease-free survival (see many examples on PMPRF’s Published Research page).

Second, the cost of treatment for diseases such as cancer is obviously a huge concern for our country as we address the rising costs of health care in general. However, the fact that CRS/HIPEC treatment “ranges from $20,000 to more than $100,000” is only part of the story. How much would it cost to treat the same patient with systemic chemotherapy alone for months or years, when experience and research shows that while it may slow tumor growth it is virtually impossible for the regimen to result in a cure? Currently, such treatment can cost up to $30,000 per month. After a successful CRS/HIPEC procedure many patients never need systemic chemotherapy. At a minimum, a more fully developed analysis of the relative cost of different treatments would be necessary to reach any reliable conclusions.

Finally, I struggle with the description early in the article that “as competition for patients and treatments intensifies,” centers are adopting CRS/HIPEC and expanding its use to treat colon and ovarian cancers. This statement seems to suggest, in very generalized terms, that use of CRS/HIPEC to treat those diseases is a financially motivated decision. Yet nothing in the article supplied proof of a connection between expanded use of the procedure and the financial motivations of particular centers or doctors. I have met many surgical oncologists who perform the CRS/HIPEC procedure not out of greed, but out of compassion. These specialists regularly endure 10 to 14 hour operating room sessions that are physically and mentally demanding, spend countless additional hours on research, and spend even more time evaluating and debating how to most effectively select the right treatment for individual patients. Yes, some of these specialists are also trying to determine whether and how a treatment like CRS/HIPEC – already proven effective for appendix cancer – may be effective for mesothelioma, ovarian, colon and other cancers that currently claim tens of thousands of lives in the United States every year. And I cannot think of better people who would more responsibly take on the weight of that challenge.

The fact that there is a sincere scientific and clinical debate about the progression of treatment options for these diseases should not overshadow the progress that has already been made and the lives that have been extended and saved by CRS/HIPEC. And the debate about when it is appropriate to treat a patient with CRS/HIPEC should not be oversimplified by the suggestion that it is only about competition and market share.

Jerry Lewandowski
President, PMP Research Foundation