Oncology Service Line: A Change in Focus
"Depending on what type of cancer it is and the biology of the cancer and how aggressive, the outcomes are variable," he says. "For ... an appendiceal cancer that's not very aggressive, you can potentially cure some of those patients, when it used to be multiple surgeries and then the patient ultimately died."
Patients with colon cancer who otherwise would live two years with standard chemotherapy now can live from four to seven years after HIPEC, Goodman says.
"Unfortunately we're not going to cure these patients for stomach cancer or colon cancer or ovarian cancer, but we do know HIPEC prolongs patient survival with good quality of life much better than standard chemo," Goodman says. "And if you do the surgery and regular chemotherapy afterward, the patient can live even longer—almost doubling or tripling their life expectancy."
While HIPEC is more common in Europe and South America, the procedure is becoming more prevalent in the United States. The procedure has been slow to catch on partially because of the difficulties of getting a program up and running due to the complexities of these patients and the costs, Goodman says.
In addition to having a surgeon trained in the procedure, a hospital looking to start a HIPEC program needs to be sure its ICUs and regular floors can handle these patients, who are more at risk for complications than typical surgical patients. A number of ancillary services will be needed, such as interventional radiology, CT scans, pathology, cardiac perfusionists, and an anesthesiologist skilled in fluid management.
"One of the hardest parts is convincing the hospital to make the investment in high-risk patients who might not have any other options. Usually it's recommended to do some type of pilot study to evaluate outcomes and help improve the program," Goodman says. "Then it comes down to surgeon comfort level. I was trained in doing these procedures, but if someone isn't trained, or is not comfortable with complex cancer surgery, they might have an increased complication rate. You're going to get complications that are higher than most other types of surgeries and [you] have to know how to deal with it."
Another difficulty in starting a HIPEC program is attracting new patients.
"Initially it's difficult to attract patients to a new program when there's already a number of established programs available to them," Goodman says. "You need a number of physicians in their organizations who are willing to refer this type of patient."
Once an organization does manage to attract patients and has a HIPEC program in place, it's critical to log results with a national database so researchers and surgeons can further hone the technique.
"Most patients with this procedure should be on a research database to help improve our knowledge of this particular disease and how we can better improve outcomes," Goodman says. "The biggest issue is the biology of the tumors—there are patients with nonaggressive tumors that recur in six months and some very aggressive tumors that might never recur. We are unable to distinguish this subset of patients. Currently, we are looking at different tumor receptors to see if there is a difference. This is similar to other types of cancers and trying to give personalized treatment versus a one-treatment-fits-all approach to everyone."
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