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Role of HIPEC in Newly Diagnosed Advanced Peritoneal Cancer

Panelists: Bradley J. Monk, MD, FACS, FACOG, University of Arizona and Creighton University; Michael J. Birrer, MD, PhD The University of Alabama at Birmingham; Ursula A. Matulonis, MD, Harvard Medical School
Published: Saturday, Dec 22, 2018



Transcript: 

Bradley J. Monk, MD: Well, to summarize, every patient needs an operation in the beginning or within the third and fourth cycle. Every patient needs germline testing as recommended by ASCO [American Society of Clinical Oncology], NCCN [National Comprehensive Cancer Network] and the ESGO [European Society of Gynaecological Oncology]. Definitely germline BRCA but probably a panel. Many patients maybe even need somatic testing because somatic testing will be part of the opportunity to use maintenance olaparib [Lynparza]. You’ve got to have a BRCA mutation to use maintenance olaparib once it’s approved, very soon. And then in the absence of that, you have bevacizumab, which may or may not be used, but I think more and more we’re using as the backbone every 3 weeks, carboplatin/paclitaxel, with less intraperitoneal chemotherapy and less dose dense weekly.

The only thing that we didn’t talk about really is HIPEC. So, HIPEC frontline was published, as you know, from the Netherlands in the New England Journal of Medicine, that showed an underwhelming PFS [progression-free survival], but a surprisingly disproportionate overall survival. So is HIPEC what we need to think about or is the pendulum going to swing and we’re just waiting?

Ursula A. Matulonis, MD:  I’ll comment about HIPEC, but I also want to, again, reiterate and add on to something that you mentioned already, [in] that you say it’s important to see a surgeon. I think it’s important to mention that surgeons should be like you, a gynecologist.

Bradley J. Monk, MD: Thank you for that.

Ursula A. Matulonis, MD:  I think that for the audience, it’s really important to know. It’s not a general surgeon or a gynecologist, it’s a gynecologic oncology surgeon. And it’s important because if we’re using more neoadjuvant chemotherapy, my fear—and I’ve seen this before in second opinions—is when the patient is started on chemotherapy.

Bradley J. Monk, MD: And then sees a surgeon, and that’s counterproductive.

Ursula A. Matulonis, MD:  Or, goes through 6 cycles of chemotherapy.

Bradley J. Monk, MD: And that’s counterproductive.

Ursula A. Matulonis, MD:  And never sees a surgeon.

Bradley J. Monk, MD: Or never is referred to a clinical trial, and that’s a missed opportunity.

Ursula A. Matulonis, MD:  Right. At Dana-Farber/Brigham [and Women’s Cancer Center], one of our surgeons has a particular interest—Michael Worley [,MD]—in doing HIPEC. So, we’ve agreed that he would see approximately 10 patients, and he would be trained on doing HIPEC, and then report to us what his results were here, and what the toxicities have been. Because in that paper, yes, there was a survival benefit, but there was also a considerable toxicity benefit, not surprisingly given the intraperitoneal cisplatin that’s given; the heated intraperitoneal cisplatin.

Bradley J. Monk, MD: And the best opportunity—at the least as published in that January 2018 New England Journal of Medicine paper—is at the time of interval debulking. So HIPEC, currently as we understand it, is not, “I have a patient with a 4th recurrence of ovarian cancer, so let’s cut her open and try to squash some chemotherapy.” [For] HIPEC, the best opportunity is you’re going to do neoadjuvant chemotherapy and interval debulking anyway, so you’re already in there. And you’ve selected the patient that’s very chemotherapy-sensitive, and now you’re trying to [get a] leg up and do a little better. Are you doing HIPEC in Alabama?

Michael J. Birrer, MD, PhD: We’re not. And although there’s been discussions about doing it, my personal view of it is if we end up doing it, we should do it in a clinical trial setting.

Bradley J. Monk, MD: So, it’s not standard.

Michael J. Birrer, MD, PhD: Exactly. And if you back to look in the New England Journal [of Medicine], it’s a relatively small study. I mean, I think it’s wonderful they did it because it’s not easy, but it’s a fairly small study. I think we need a confirmatory study before we would adopt that widely. It is toxic too.

Transcript Edited for Clarity

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Transcript: 

Bradley J. Monk, MD: Well, to summarize, every patient needs an operation in the beginning or within the third and fourth cycle. Every patient needs germline testing as recommended by ASCO [American Society of Clinical Oncology], NCCN [National Comprehensive Cancer Network] and the ESGO [European Society of Gynaecological Oncology]. Definitely germline BRCA but probably a panel. Many patients maybe even need somatic testing because somatic testing will be part of the opportunity to use maintenance olaparib [Lynparza]. You’ve got to have a BRCA mutation to use maintenance olaparib once it’s approved, very soon. And then in the absence of that, you have bevacizumab, which may or may not be used, but I think more and more we’re using as the backbone every 3 weeks, carboplatin/paclitaxel, with less intraperitoneal chemotherapy and less dose dense weekly.

The only thing that we didn’t talk about really is HIPEC. So, HIPEC frontline was published, as you know, from the Netherlands in the New England Journal of Medicine, that showed an underwhelming PFS [progression-free survival], but a surprisingly disproportionate overall survival. So is HIPEC what we need to think about or is the pendulum going to swing and we’re just waiting?

Ursula A. Matulonis, MD:  I’ll comment about HIPEC, but I also want to, again, reiterate and add on to something that you mentioned already, [in] that you say it’s important to see a surgeon. I think it’s important to mention that surgeons should be like you, a gynecologist.

Bradley J. Monk, MD: Thank you for that.

Ursula A. Matulonis, MD:  I think that for the audience, it’s really important to know. It’s not a general surgeon or a gynecologist, it’s a gynecologic oncology surgeon. And it’s important because if we’re using more neoadjuvant chemotherapy, my fear—and I’ve seen this before in second opinions—is when the patient is started on chemotherapy.

Bradley J. Monk, MD: And then sees a surgeon, and that’s counterproductive.

Ursula A. Matulonis, MD:  Or, goes through 6 cycles of chemotherapy.

Bradley J. Monk, MD: And that’s counterproductive.

Ursula A. Matulonis, MD:  And never sees a surgeon.

Bradley J. Monk, MD: Or never is referred to a clinical trial, and that’s a missed opportunity.

Ursula A. Matulonis, MD:  Right. At Dana-Farber/Brigham [and Women’s Cancer Center], one of our surgeons has a particular interest—Michael Worley [,MD]—in doing HIPEC. So, we’ve agreed that he would see approximately 10 patients, and he would be trained on doing HIPEC, and then report to us what his results were here, and what the toxicities have been. Because in that paper, yes, there was a survival benefit, but there was also a considerable toxicity benefit, not surprisingly given the intraperitoneal cisplatin that’s given; the heated intraperitoneal cisplatin.

Bradley J. Monk, MD: And the best opportunity—at the least as published in that January 2018 New England Journal of Medicine paper—is at the time of interval debulking. So HIPEC, currently as we understand it, is not, “I have a patient with a 4th recurrence of ovarian cancer, so let’s cut her open and try to squash some chemotherapy.” [For] HIPEC, the best opportunity is you’re going to do neoadjuvant chemotherapy and interval debulking anyway, so you’re already in there. And you’ve selected the patient that’s very chemotherapy-sensitive, and now you’re trying to [get a] leg up and do a little better. Are you doing HIPEC in Alabama?

Michael J. Birrer, MD, PhD: We’re not. And although there’s been discussions about doing it, my personal view of it is if we end up doing it, we should do it in a clinical trial setting.

Bradley J. Monk, MD: So, it’s not standard.

Michael J. Birrer, MD, PhD: Exactly. And if you back to look in the New England Journal [of Medicine], it’s a relatively small study. I mean, I think it’s wonderful they did it because it’s not easy, but it’s a fairly small study. I think we need a confirmatory study before we would adopt that widely. It is toxic too.

Transcript Edited for Clarity
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