Among the merits of good clinical studies, according to David P. Ryan, MD, of Massachusetts General Hospital Cancer Center and Harvard Medical School, is being able to cite them when a physician sits down with a patient to explain the possible benefits and drawbacks of treatment. Dr. Ryan stressed, however, that such studies are lacking for cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). “In the absence of good data,” he said, physicians should explain to patients that “this is a highly debated area. Nobody knows for sure what the overall impact of this procedure is.”

He said he tells a patient, “While I’m not a supporter of the procedure, I am supportive of you, and if you want to talk to one of the surgeons who does this all the time, by all means do so. But I can tell you that we really don’t know what impact, if any, this will have on the natural history of your cancer.”

Informed Decisions

“I think physicians ought to inform patients that these treatments are available, and it then becomes the patient’s decision,” commented Paul H. Sugarbaker, MD, of Washington Hospital Center in Washington, DC. “A lot of people come to me and say, ‘I’m just here for information. I want to know what your statistics are, and here’s my particular situation. What do you think?’ Some of them come back and some of them do not.”

Dr. Sugarbaker’s advice to colleagues is to refer patients early and “minimize surgery if they think the patient might be a candidate for cytoreductive surgery and HIPEC. If the patient has a primary colon cancer, that must be dealt with. But leave the peritoneal metastases for the peritoneal surface oncology team.”

At the Washington Hospital Center, the procedure is a multidisciplinary effort, he noted. “The patients come from the colorectal surgeons. We discuss the patients. They get their FOLFOX chemotherapy. Five months later, they are back in the operating room and having their definitive peritonectomies and intraperitoneal chemotherapy.” ■