Intraperitoneal Chemotherapy: A Better but Underused Option for Women with Advanced Ovarian Cancer

By Maureen Salamon,

Tuesday, October 6, 2015

Illustration of chemotherapy being delivered to intraperitoneal space of human.
Summary

Intraperitoneal (IP) chemotherapy delivers drugs directly into the abdominal cavity, bathing cancer cells in them. Though the treatment, which was pioneered for ovarian cancer at Memorial Sloan Kettering in the 1980s, is highly effective, it remains underused at other cancer hospitals. MSK gynecologic surgeon Dennis Chi discusses how it works, which patients benefit most, and why some doctors may still be reluctant to use it.

Highlights
  • Intraperitoneal (IP) chemotherapy delivers drugs into the abdomen.
  • It was pioneered at MSK in the 1980s for ovarian cancer.
  • It has proven to be effective in multiple studies.
  • The treatment is still surprisingly underused by many doctors.

Intraperitoneal (IP) chemotherapy, which delivers drugs directly into the abdominal cavity, has long been known to significantly extend the lives of women with advanced ovarian cancer. But despite the treatment’s success, a widely reported recent study showed that nearly half of American hospitals don’t offer IP chemotherapy to eligible patients.

This underuse persists despite decades-old research showing the treatment could add 16 months or more to women’s lives compared with intravenous (IV) chemotherapy alone when used after optimal debulking surgery, which usually involves removing not only the ovaries but also the uterus, cervix, fallopian tubes, and most or all visible tumor cells.

MSK pioneered IP chemotherapy in the 1980s and has long considered the treatment to be the standard of care for ovarian cancer. Dennis Chi, Deputy Chief and Head of the Section of Ovarian Cancer Surgery, discussed with us how IP chemotherapy works, who is most likely to benefit from it, and how MSK has led the development of the treatment.

How is IP chemotherapy given at MSK?

We perform IP chemotherapy on an outpatient basis after optimal debulking surgery. A catheter is surgically inserted into the patient’s abdomen and connected to an access port that is implanted under the skin. This allows chemotherapy to be dripped into the peritoneal cavity — the area between the muscles and the organs in the belly. We ask the patient to move around periodically during the infusion to make sure the chemotherapy fluid distributes throughout the peritoneal space. The process takes a few hours, and then the patient can go home. The infusion is repeated five times over a period of months.

We perform IP chemotherapy on an outpatient basis after optimal debulking surgery.
Dennis S. Chi
Dennis S. Chi gynecologic surgeon
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Why does this form of chemotherapy appear to work better than standard IV therapy in many patients?

It’s not completely known why it works as well as it does. Since the chemotherapy fluid remains in the abdomen and dissipates over time, the obvious first theory is that we’re bathing cancer cells in it. Another theory is that it’s a double hit, since the chemotherapy then gets absorbed into the bloodstream and goes to the cancer a second time.

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Which patients are most likely to benefit from IP chemotherapy?

There are no hard-and-fast rules, but the patients who benefit the most tend to have stage III ovarian cancer, in which the disease has spread beyond the ovaries but is confined to the abdomen. About 65 percent of our patients have been diagnosed with stage III cancer and have received optimal debulking surgery. About two-thirds of these stage III patients undergo both IV and IP chemotherapy following this surgery. We may also consider IP chemotherapy for patients with stage IV ovarian cancer if extensive surgery has first removed all visible tumor traces, even if the disease has spread to the liver or spleen.

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What are possible side effects of this treatment?

Since the chemotherapy fluid stays in the abdomen while it’s absorbed, patients can temporarily feel bloated and uncomfortable after the procedure. A 2006 study also showed that the treatment can trigger more digestive problems, fatigue, low blood counts, and tingling and pain in the limbs than IV chemotherapy. Our later research at MSK showed that modifying the dosage of the therapy decreased all these side effects. Once patients are off the treatment for six months or longer, their side effects greatly decrease as well.

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Why do you think IP chemotherapy hasn’t been more widely used across the United States, despite its clear benefits?

Like many other aspects of medicine, it first comes down to whether you believe the research. There are skeptics who think there may have been flaws in the studies and others who believe in it but feel IP chemotherapy is too cumbersome for them to administer or for patients to receive. It’s certainly one of the more technically challenging chemotherapies to give, and you do need experience giving it.

Also, some institutions aren’t as proactive as we are with optimal debulking surgery and choose to do surgery after first giving IV chemotherapy. This approach leaves fewer advanced ovarian cancer patients eligible to receive IP chemotherapy. Upcoming results from ongoing national trials should shed even more light on which approach may benefit patients more.

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What factors make MSK a leader in the use of IP chemotherapy?

What makes us a leader is our vast experience of giving it and learning to anticipate and deal with the potential complications. To my knowledge, MSK performs more ovarian cancer debulking surgical procedures than any other single institution in the United States. We also have one of the largest volumes of patients in the world that have undergone IP chemotherapy.   

Many patients have come to us for IP chemotherapy who have had problems getting it elsewhere, such as ports malfunctioning or fluid being infused into the wrong part of the abdomen. We have such a long track record here that there’s very little in terms of things going wrong that somebody on our staff hasn’t seen before. They know that mild glitches happen and not to give up.     

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Comments

I had stage IV Ovarian Cancer in 1990. After Debulking, 6 months of IV chemo, and a clean second look surgery, I was treated at MSKCC with Intraperitonial Wash for 3 more months. Thankfully, for the doctors at MSKCC, I am fine and have not relapsed in 25 years.

Sheila, thank you for your comment, and we are glad to hear you are doing well!

I would be interested in knowing more. I was diagnosed with Stage III PPC in 05/13. I went through the debulking surgery; the carboplatin and taxol txs, which were very effective. However, 6 mos. later the numbers went up and i am now on Avastin but my numbers have plateaued.

Two years ago, I had Stage III ovarian cancer. I had surgery, then 6 cycles of Carboplatin and Paclitaxel (dose dense). I was told IP chemo was an option, but if I had it and the cancer came back, I wouldn't be able to have it again. Do you find this to be true?

Mary Ann, we sent your question to Dr. Chi, who replied, "Different institutions have different policies on when they give IP chemotherapy and whether or not a patient can get IP chemotherapy during primary therapy and then again at the time of recurrence. At MSK, we currently give IP chemotherapy only during primary therapy, and we have a protocol to give heated IP chemotherapy during debulking for recurrent disease. Getting IP chemotherapy during primary therapy does not exclude patients from going on our heated IP chemotherapy trial. Again, other institutions may have different approaches and protocols regarding giving IP chemotherapy to patients with recurrent disease." Thank you for your comment.

On 7-29-15 Dr Sonoda did my surgery and also inserted my IP. I was given (my hometown) chemo per surgeons recommendation. After only two treatments into IP I was having kidney failure. I am receiving chemo now only through chest port (Carbo/taxal). I was diagnosed with stage 3. With only receiving two treatments (into IP) will that have any positive effect?

Dear Diane, we are sorry to hear about your health issues. We would encourage you to ask Dr. Sonoda about the benefits you may have received from having had two IP treatments along with the additional chemotherapy you've had. He knows your particular circumstances best and can offer a more informed opinion. Thank you for reaching out to us.

I'm currently diagnosed with Stage 3c, OVC. I have IP and IV chemo. I start round 4 on Monday.
What will be the tests used to follow me after the chemo is done? My CA125 was 32 before my debulking surgery and my CT scan was clear before my first chemo treatment.

Hi, Kathleen, in general, we offer comprehensive follow-up care for people who’ve been treated here as part of our institution-wide Survivorship Initiative. To learn more about follow-up care for people with ovarian cancer, please visit https://www.mskcc.org/cancer-care/types/ovarian/treatment/follow-up. However, we do recommend that you ask your oncologist, who knows the unique details of your diagnosis and treatment regimen. He or she would be better able to answer your questions regarding what tests would be used to specifically monitor you after your complete your treatment. Thank you for reaching out to us.

I work in a cancer center and am looking for more resources on the actual procedure of IP chemotherapy, including how to access and IP catheter, and how chemo is actually administered. Thanks.

My sister was treated successfully with debulking, carboplatin and taxol for 6 months in 2014. On regular MRI,July 2016 there are multiple hemorrhagic cysts in the pelvis and abdominal wall. PET Scan doesnot show any FDG-2 uptake at all. Do u recommend another surgery+/- chemotherapy?

HI Sameerah, we are not able to make individual recommendations on our blog. If your sister would like to have a consultation with one of our doctors, she can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment.

Hi, I have recurrent metastatic cervical cancer that seems to be confined to recurring in my abdomen (not in new specific organs). Has IP treatment been given for other cancer types that have metastasized the same way as the target patient with Ovarian cancer?

Hi Rachel, according to Dr. Chi MSK does not offer IP chemotherapy for cervical cancer. If you'd like to make an appointment to speak with someone about what other treatment options may be available, including clinical trials, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment to find out more about making an appointment. Thank you for your comment.

My sister was diagnosed over 7 years ago with Stage 3 ovarian cancer. After surgery and initial chemo the cancer reoccurred after 22 months. She has now exhausted all IV chemotherapy drugs having gone through 9 different IV drugs. She now has tumors in abdomen, liver and bladder and has been told there is no more that can be done. She is now under palliative care with TPN. Is there anything MSK can offer?

Dear Molly, we are so sorry to hear about your sister's diagnosis and everything she's been through.

If she would like to make an appointment to consult with one of our specialists about possible treatment options, please call our Physician Referral Service at 800-525-2225. In the meantime, she may be interested in browsing through our open clinical trials for people with advanced ovarian cancer here: https://www.mskcc.org/cancer-care/types/ovarian/clinical-trials.

Thank you for reaching out to us.

I was wondering if you happen to know any centers any/or hospitals near Indianapolis, IN that offer IP chemotherapy? Or do you know any way to find out without having to call them all?

Hi Mary Kay, you can ask your doctor for a referral. If your doctor is unaware of which hospitals offer this treatment option, you may want to find a National Cancer Institute-designated cancer center near you and speak with them about it. You can find a list at https://www.cancer.gov/research/nci-role/cancer-centers/find. Thank you for your comment.

I was wondering if it is any oral drug on the market to prevent Recurrence of fallopian tube cancer? I was diagnosed with stage IIIbfallopian tube cancer BRACA1 positive. I had surgery and 6 chemoterapy with weekly Texol. My doctor did not suggest IP chemotherapy .

My 24 year old otherwise healthy daughter was diagnosed with stage 11 ovarian cancer in March 2015. She had surgery to remove the one affected ovary and then went through 6 rounds of the standard chemotherapy. By August 2015, she was in remission. Come May 2016, her cancer has returned. She again went through the standard chemotherapy treatment which at the end of the cycles saw her tumors as stable. Come October 2016, Avastin was added to the standard chemotherapy but as of December 2, 2015, her tumors have grown significantly. Her doctor is not sure what the best next option is (surgery, radiation, or more chemotherapy). Given these facts, would seeing one of your doctors for a consult be fruitful (if not more encouraging than her doctor is)?

Hi Norma, we are so sorry to hear that your daughter is going through this. We have a number of treatments that we can offer to patients with ovarian cancer, including clinical trials. If your daughter would like to come here for a consultation, you can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment.

I was first diagnosed in 2007 with PPC stage 3C. I had surgery with IP and IV chemo. I had two recurrences in 2012, had surgery and IV chemo. Oct. 2016 I had a return of PPC and had the tumors removed and had HIPEC. I am to start IV chemo. this week. I am still having a lot of abdominal pain following the HIPEC procedure. Is this normal?

Dear Michelle, we are sorry to hear about your diagnosis. Everyone recovers differently from surgery and other invasive medical procedures. It's best to talk to your oncologist about any pain or other symptoms you may be having so that he or she can take the necessary steps to address it.

Wish you well as you continue with your treatment. Thank you for reaching out to us.

I was just diagnosed with ovarian cancer stage 4. It has not spread to my organs but cancer cells are present in pleural cavity. My oncologist is recommending a 3-month course of carboplatinum and taxel. She is recommending debulking surgery after chemo if necessary. SHould I consider having debulking surgery first before chemo?

Dear Gail, we are sorry to hear about your diagnosis. If you would like to make an appointment with one of our specialists for a second opinion about possible next steps in your care, please contact our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

I just found this site while researching for my sister who recently underwent surgery for ovarian cancer (I don't know all of the technical terms). Her oncologist determines it is Stage IV with spread to the sacks surrounding organs, and she has unrelenting edema, having been drained at least four times since her surgery.
She is being treated by physicians associated with Cedars Sinai; are they doing IP in this area? I saw USC and UCLA on your list. Are there specific oncologists we can also contact? She had her first infusion a few days ago.
Thank you, Amy

Dear Amy, we are sorry to hear about your sister's diagnosis. It's best for her to consult with her oncologist to see if this treatment approach is offered at Cedars Sinai and ask if it's appropriate for her. If she is at a point in her treatment where she needs to make decisions about next steps in her care and she would like to come to MSK for a second opinion, she is welcome to make an appointment with one of our specialists by calling our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

Is there any information,suggestions or blog that can give information to help a patience get through IP Chemo? I know some of the side effects can be very uncomfortabe and I wanted to know if anyone had suggestions of anything that may make this treament bearable?

Dear Heather, you may find this patient education information on our website helpful: https://www.mskcc.org/cancer-care/patient-education/intraperitoneal-the…. Your oncologist may also have additional suggestions and guidance, so we would recommend that you follow up with him or her regarding any specific concerns you may have as you prepare for this treatment. Thank you for reaching out to us.

Im currently speaking on my mother-in-laws behalf. She was diagnosed about 2 years ago with stage IV Ovarian. Shes recieved several different chemos and has been told they work for a short amount of time then stop. Due to a certain gene. After a recent biopsy of her left lymphnode near her breast. It was found positive for ovarian cancer and that theres nothing they can do anymore. Is there a possibility this form of treatment could be viable?

Dear Chase, we're sorry to hear about your mother-in-law's diagnosis. If she would like to meet with someone at MSK to find out about what treatment options may be available, she can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. Thank you for your comment, and best wishes to you and your family.

I'm having reversal of ileostomy placement of IP my CEA # went up 10.8 from# 2 three months ago. My choice for this application instead of HIPEC is IP using 5fu. Hoping I made the correct choice. 5fu was used during my iv chemo and reduced cea down from 24 to 2. Thank you Dr Nash. My surgery is scheduled 3/22/17

Dear Philip, best wishes to you on your upcoming surgery. Thank you for your comment.

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