In Support of HIPEC as Standard of Care for Stage 3 Ovarian Cancer

At the 2022 Great Debates & Updates in Women’s Oncology virtual meeting, Oliver Zivanovic, MD, Memorial Sloan Kettering Cancer Center, defended the merits of hyperthermic intraperitoneal chemotherapy (HIPEC) as standard-of-care treatment for late-stage ovarian cancer.

In his presentation, Dr Zivanovic covered the importance of selecting the correct patients with ovarian to receive HIPEC and highlighted studies supporting HIPEC as standard of care for these patients.

Transcript

Hi, my name is Oliver Zivanovic. I'm a gynecologic cancer surgeon at Memorial Sloan Kettering Cancer Center in New York. I'm an associate attending there, and I wanted to give you an update on the role of hyperthermic intraperitoneal chemotherapy for patients with ovarian cancer. It's a great honor to be presenting my take on it, and I'm extremely excited about the opportunity to be here.

HIPEC, also known as hyperthermic intraperitoneal chemotherapy, is a very controversial treatment modality. There have been many conversations about it. There are strong feelings about it. Some are completely against it, while others are completely for it. I think it's important to discuss this topic shortly and briefly here, and I'm very happy to share my opinion, which is also the position of my institution.

HIPEC means delivering chemotherapy in the operating room (OR) while the patient is undergoing a surgery for ovarian cancer. We typically use medications that are well-known, such as cisplatin or carboplatin. HIPEC has also been used for other cancers and other solid tumors such as colon cancer, appendiceal cancer, and mesothelioma, but I'm only going to focus on ovarian cancer at this point.

The rationale of giving hyperthermic intraperitoneal chemotherapy is that ovarian cancer stays in the abdominal compartment and metastasizes in the peritoneum very frequently. The idea to treat tumor cells in the peritoneum locally has been established for a long time. In fact, there have been multiple studies regarding giving intraperitoneal chemotherapy through a port into the belly for the past 20 or 30 years. Unfortunately, this modality has been abandoned because new treatments, intravenous treatments, have shown to be equally effective and less toxic.

However, giving 1 dose of chemotherapy in the OR while the patient is under anesthesia and undergoing a necessary procedure for the ovarian cancer is appealing because it is both effective and cost-effective. You don't lose much time between surgery and the first dose of chemotherapy. If we can show that it works, the drugs that are given are also not very expensive compared to other compounds and maintenance treatments. In addition, it is not a treatment that deprives the patients from further standard-of-care, experimental, or maintenance treatments down the road. It's just an additional treatment while the patient is in the OR.

One study that was published in 2018 from Europe showed that patients who had chemotherapy for their ovarian cancer and then went to the OR for interval surgery, those patients who were treated with 1 dose of cisplatin while in the OR for 90 minutes did better in terms of progression-free and overall survival than patients who had surgery alone without this treatment. This triggered a lot of conversation. Since the study was published, the national guidelines have accepted this as a standard of care in patients with advanced ovarian cancer who started their treatment with chemotherapy.

Now, we, at our institution, do offer this as a standard of care in exactly that setting. It is very important to state here that patients with recurrent ovarian cancer or patients with the initial diagnosis of ovarian cancer who did not have chemotherapy initially, but were chosen to undergo surgery first, are not candidates for this treatment because there are no studies to support the benefit of this in these patient populations. HIPEC is for those patients with stage 3 ovarian cancer who started their cancer journey with chemotherapy upfront and go to the OR later.

I think we have good data about the safety of this approach. In the past 10 years, multiple studies have shown that giving this dose of chemotherapy while the patient is in the OR is relatively safe. There is some increased risk of renal toxicity, so kidney injuries after surgery with this 1 dose of cisplatin are being reported. However, you can mitigate this risk by giving drugs that protect the kidney during the surgery and by choosing the right patients who don't have preexisting renal conditions for this type of treatment.

When you select the right patients in the right setting, HIPEC is an extremely safe method to deliver chemotherapy. It is effective because the patient is under anesthesia, is undergoing surgery for ovarian cancer. You’re not doing this anesthesia for the chemotherapy. You're doing the chemotherapy because the patient is already indicated for that necessary procedure. It’s not an extra day of OR just because of the chemotherapy. It’s the other way around. Patients need to go to the OR to have necessary surgery, and we're seizing this moment to deliver this drug intraperitoneally.

In conclusion, I think giving chemotherapy in the OR as HIPEC, especially cisplatin, has been shown to improve progression-free in overall survival in the very select group of patients with stage 3 ovarian cancer, who started chemotherapy first and go to the OR later. It is not proven in any recurrent setting of ovarian cancer. It is also not proven in the upfront setting where patients present with ovarian cancer and go to the OR first.

We are looking at multiple new studies on the way to look at the role of HIPEC in the recurrent setting or in the primary setting, but those results are not going to be released for the next 2 to 5 years, I would assume. Also, in the United States, the Gynecological Oncology Group partners are planning a study combining surgery and HIPEC with cisplatin and also using maintenance treatments with PARP inhibitors. Hopefully, this study is going to start accruing next year.

So altogether, HIPEC is a very safe treatment modality, but it's important to use it in the right patients. We should not offer it to every patient with ovarian cancer. There are strict selection criteria. We should stay with the science. When used correctly, it is safe and may improve the outcomes of our dear patients with ovarian cancer, who are fighting this disease. Thank you so much.

Source

Zivanovic O. Debate: HIPEC: Standard of Care? - YES. Presented at: Great Debates & Updates in Women’s Oncology. Sep 21-23; 2022; Virtual.