Heated Chemotherapy: Using Robust Science to Guide Clinical Decisions

Pictured: Oliver Zivanovic, Garrett Nash & Dennis Chi

Surgeons Oliver Zivanovic, Garrett Nash, and Dennis Chi are leading novel studies of a procedure called hyperthermic intraperitoneal chemotherapy, also known as HIPEC.

A procedure called hyperthermic (heated) intraperitoneal chemotherapy, or HIPEC, has shown some promise in early studies for certain types of cancer. Although a number of hospitals in the country are now offering HIPEC, the data to support its use is limited, and some experts argue that more research is needed to evaluate the risks and benefits of the approach, which patients are most likely to benefit, and whether it is better than standard therapies.

Now experts at Memorial Sloan Kettering have set out to attain conclusive scientific evidence to determine the effectiveness of HIPEC in patients with colorectal or appendix cancer, and in women with certain gynecologic cancers.

HIPEC is based on a related approach that involves the delivery of unheated chemotherapy directly into the lining of the abdominal area, known as the peritoneal cavity, through a surgically implanted catheter. This technique allows a high concentration of medication to reach the area where the cancer was surgically removed in order to treat residual cancer cells. Pioneered at Memorial Sloan Kettering, the technique — known as intraperitoneal chemotherapy (IPC) — has been shown in several trials to extend survival among patients with certain cancers when delivered in the days or weeks following surgery.

Heating Chemotherapy to Boost Effect

Laboratory evidence suggests that heat makes cancer cells more sensitive to certain chemotherapy agents and may improve the ability of those drugs to penetrate and kill cancer cells more efficiently. During HIPEC, surgeons heat chemotherapy to around 107 degrees Fahrenheit and infuse it into the peritoneal cavity immediately after surgery is completed.

“This approach allows surgeons to give higher doses of anticancer drugs than they can intravenously, directly exposing any remaining cancer cells to a ‘bath’ of chemotherapy,” says gynecologic surgeon Oliver Zivanovic. “However, it is not an insignificant procedure, adding another two hours of time in the operating room while the patient is under anesthesia.”

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Risks and Benefits of HIPEC

HIPEC has been studied in patients with appendix cancer, peritoneal mesothelioma, colorectal cancer, uterine cancer, and ovarian cancer — solid tumors with a similar propensity to spread to the peritoneal lining. Some studies have reported complications such as decreased white blood cell count, anemia, low platelets, gastrointestinal issues, and neuropathy, a nerve problem that causes pain, numbness, tingling, swelling, or muscle weakness.

On the other hand, because HIPEC delivers cancer drugs directly to the area where microscopic cancer cells may persist, and only a small portion of a given drug is absorbed into the blood stream, side effects such as nausea are minimal compared to those that can occur with multiple cycles of traditional, intravenous chemotherapy. In addition, a number of early studies have shown HIPEC to be safe. One trial conducted in Europe demonstrated a survival advantage of surgery with HIPEC compared to systemic chemotherapy alone among patients with colorectal cancer.

At Memorial Sloan Kettering, HIPEC is offered to patients only within the context of clinical studies. A specially trained team of experienced surgeons, nurses, and anesthesiologists works together to safely administer the treatment, operate the equipment, and monitor the patient. Radiologists are also involved to ensure the careful review of radiologic images taken before and after surgery.

“A number of US hospitals have begun offering HIPEC as a treatment option outside of the clinical trial setting based on positive data from small studies evaluating a single group of patients without a control group for comparison,” says Dr. Zivanovic, who is Director of Innovative Surgical Technology at Memorial Sloan Kettering. “Rather than extrapolating from those results, we have chosen to carefully study this approach in randomized clinical trials.”

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Studying HIPEC for Gynecologic Cancers

Memorial Sloan Kettering is the first cancer center in the United States to offer a randomized clinical trial to study HIPEC in women who are having surgery for a recurrence of ovarian, fallopian tube, or peritoneal cancer. The study — in which patients are arbitrarily assigned to one of two treatment groups and followed prospectively over time — is helping researchers learn which approach provides the best balance of safety and effectiveness.

“This phase II study will provide the most reliable, unbiased information about whether HIPEC really does make a difference in the outcomes of patients with these cancers,” says gynecologic surgeon Dennis S. Chi.

Half of the patients will receive HIPEC followed by five cycles of intravenous chemotherapy after the surgery. The other half will receive six cycles of postoperative intravenous chemotherapy. Investigators will follow patients for two years after the treatment to compare the incidence of recurrence and side effects between the two groups.

“It is important to understand which patients are most likely to benefit from HIPEC and whether it is as good or better than standard therapy based on how long they remain free of disease progression. If the results support it, we will be able to confidently recommend HIPEC as a treatment option for these patients,” adds Dr. Chi, who is the principal investigator of the study.

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Exploring Effectiveness in Colorectal and Appendix Cancers

Memorial Sloan Kettering is also offering a randomized, phase II clinical trial comparing HIPEC to EPIC in patients with metastatic colorectal cancer or appendix cancer. It will be the first-ever prospective trial of any treatment for patients with appendix cancer worldwide, and the first randomized trial of IP chemotherapy for patients with colorectal cancer in the United States.

Patients will be randomly assigned to one of two groups to receive either HIPEC at the time of surgery or early postoperative intraperitoneal chemotherapy (EPIC), which is delivered for three days immediately following surgery. Researchers will compare the number of patients in each group who remain free of disease recurrence after three years and compare complication rates and changes in the quality of life of the patients undergoing each treatment. They will also collect tumor tissue to identify unique genetic markers that may make the cancers more sensitive to certain treatments, including the chemotherapies used in the trial and other types of drugs.

“Our goal is to have a balanced trial that will determine which of these treatments is superior and provide information we need to guide future patient management,” says oncologic surgeon Garrett M. Nash, who is leading the trial.

“If our findings show that HIPEC is safe and effective, we may have an opportunity to explore whether the effectiveness of other types of treatments such as targeted drugs and immune therapies can also be enhanced using this approach,” adds Dr. Zivanovic.

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Hi at Mskkcc, nice to hear that you are exploring other therapies to combat this deadly disease.. I was randomized to receive radiation therapy as part of the CHOP treatment for NHL, before undergoing an Autologous Transplant in 2002, rather than additional CHOP therapy... This decision saved my life... One size doesn't fit all ..... Thank You for the wonderful life saving work you do at this World Class Facility...

I had cancer from my Appendix Sept. 2011 and went through HIPEC- I also had many organs removed. I am a 52 year old women, I am feeling great and back to normal. It was a tough time, but I survived…It does work

Terri at what point was HIPEC done on you? Did you have surgery or chemo first? What side effects did you encounter from HIPEC? This procedure has been discussed as an option for me, just not sure i want to unergo it.

I was diagnosed with appendix cancer with PMP in 2007. I was treated at MSK using EPIC soon after my surgery followed by 12 cycles of chemo. The entire treatment was just under 1 year due to few delays from low WBC, & platlets.
There were a few rough spots in the beginning with my hands & feet from the systemic chemo but once the right dose of neurontin was found things improved. HIPEC & the extensive surgery wasn't for me. It would have been a last resort. I have no regrets. I am very healthy today with no recurrence.

Hilary, thank you for sharing your story. We’re glad to hear you’re doing well.

In February 2014 my wife was diagnosed and treated (CRS, C1) for appendiceal cancer (primary), metastasized throughout the peritoneum (St. IV-B). Cytopathology revealed exclusively low-grade cells. I have been unable to find a single paper in the literature describing a prospective, randomized, multi-center trial comparing CRS +/- HIPEC (or EPIC). In February 2005, Miner et al. at your institution expressed skepticism about the procedure. Anecdote is not data. The plural of anecdotes is not data. Has there been any data since then?

Eric, we are looking into this and will let you know when we’re able to get some information for you. Thank you for your comment.

Dear Dr. Sharps, we sent your inquiry to Dr. Nash and he responded: “There have been no randomized trials of treatment for low grade appendix cancer. All data is retrospective and/or not controlled. We are doing the first trial in the world which will assess the efficacy of IP chemo for appendix cancer (ICARuS).”

If your wife would like to make an appointment for a consultation with one of our specialists, please call our Physician Referral Service at 800-525-2225. Thank you for your comment.

Thank you Dr. Nash. ICARuS will not address whether chemotherapy is beneficial or not, since every patient enrolled will receive HIPEC or EPIC. In any case, my wife would be excluded from the trial based on the first and third exclusionary criteria. The natural history of appendiceal neoplasm (low- or high-grade) with PMP, post CRS, absent antiproliferative chemotherapy (systemic or HIPEC/EPIC) will remain unknown. Perhaps the French study (Prodige-7?) will be informative.

My husband was operated on in March at a hospital in NJ for removal of a polyp near his appendix. When they opened him up they found appendix cancer. The surgeon did the debulking procedure but the HIPEC treatment was not available at that facility. I made an appointment with one your the doctors at Sloan, who is currently treating him. At time of surgery 18 lymph nodes were removed and found to be negative. CAT scan taken a few weeks ago at Sloan showed the cancer had spread to his liver and 1 lymph node and they weren't sure weather a spot in his pelvis was a problem or from surgery. He had a port implanted and is receiving Chemo for two days every other week. The doctor said that because the cancer had spread he was not a candidate for HIPEC and the best course of action was his current chemo treatment. I want to be proactive with regard to his treatment, so I am questioning if he is getting the BEST treatment available at Sloan for his condition and to extend his life. Are the physicians at Sloan knowledgable about the treatment options offered by Drs Fournier and Mansfield at M.D. Anderson in Houston and would my husband be a candidate for such treatment.
Respectfully submitted,
Carol Smith

Dear Carol, we are sorry to hear that your husband’s cancer has spread. Rest assured, he is in good hands. Your husband’s physician and the disease management team that is managing his care would be knowledgeable about which treatment would be most helpful for your husband’s specific situation.

Memorial Sloan Kettering has taken a leadership role in the development of HIPEC. It is still the subject of investigation here and at other hospitals, so it may be unclear which patients will benefit. HIPEC is currently being compared to another treatment called EPIC in patients with metastatic appendix cancer in the context of a clinical trial. We won’t know which is more effective until the results are published. Here is the link to the study for more information: http://www.mskcc.org/cancer-care/trial/12-289.

There are strict criteria for participation in any clinical trial, so we would recommend that you and your husband discuss whether he is a candidate for this trial with his physician at Memorial Sloan Kettering.

Thank you for your comment.

You have been doing EPIC for a long time now, what kind of success has it achieved? If someone had to choose between EPIC and HIPEC now, before trial results, which would be the better course? Would a doctor at msk ever refer to another hospital because msk does not offer HIPEC at this time?

Dear Fred, we sent your inquiry to Dr. Nash and he responded:

“The reported results of HIPEC and EPIC for colon and appendix cancer, in the best hands, are equivalent. In order to conduct a trial, such as ICARuS, the investigators must demonstrate to the Institutional Review Board that there is no evidence that one treatment is better than the other. If EPIC or HIPEC were already found to be superior, the trial would not approved as it would be unethical. To date, about 80% of patients who are deemed eligible and are offered participation in the ICARuS trial at MSK decide to enroll in the trial, 10% have chosen to have treatment with EPIC at MSK but outside of the trial, and 10% have gone elsewhere for HIPEC. I have suggested other hospitals who do intraperitoneal therapy when patients who consult with me wish to have a 2nd opinion or have treatment closer to home.”

If you are interested in making an appointment at Memorial Sloan Kettering and have additional questions about this trial, please call our Physician Referral Service at 800-525-2225. Thank you for your comment.

I've been receiving care from Dr Nancy Kemeny for the past two years. After getting an unacceptable prognosis from three other hospitals. This woman is amazing!! Her compassion exudes her and I'm still here. I have stage four CRC but since being treated by Dr. Kemeny, 30+ tumors that matastisized to my liver are gone! My last CTscan, however revealed a couple of tumors in my abdomen. We discussed a clinical trial for the BRAF MUTATION and decided that surgery to remove them is better due to the fact that there has been no complete cancer removal thus far in the study. My liver is still clean and I will be discussing with the surgeons next week about their surgery trial which, after looking at all the options, seem the best path to being cancer free.

Can Dr. Nash comment on the relative risk/toxicity of HIPEC or EPIC relative to traditional multi course systemic chemotherapy? Does their addition to CRS increase the risk of major surgical complications?

Dear Dr. Griswold, we have forwarded your questions to Dr. Nash and he will respond to you directly via the email address you provided. Thank you for your comment.

Question for Dr Nash: in a patient with currently unresectable liver metastasis (colon primary removed) being treated by HAI, is EPIC a potential option to treat a) new abdominal implants and/or b) preemptive treatment given a peritoneal implant was removed during colon resection? Does having HAI pump preclude one from having EPIC or HIPEC? Thank you.

SG, we sent your question to Dr. Nash, and he replied, “If a patient already has an HAIP and his or her liver disease is well controlled, we sometimes use EPIC to treat low-volume surgically debulked peritoneal disease.” Thank you for you comment.

I understand from a recent news coverage that doctors in Washington have developed a procedure of identifying the DNA code of surgically removed cancer cells from a patient. With this data in hand a chemo treatment is developed which when administered to the patient was successful in eliminating the patient's cancer tumors. It was stated that this treatment has been applied to other types of cancer cases with success. Is this this specific type of research being looked into or being done at MSK?

Joseph, thank you for your comment. Memorial Sloan Kettering physicians are studying the genomic characteristics of tumors and this sometimes suggests therapies that have shown greater effectiveness than standard unselected treatments.

Hi, I just found this thread. I have stage 4 colon cancer that metastasized to my ovaries and fallopian tunes. I had initial surgery May 2013 and 2 tumors grew back in my pelvis area. I had Hipec in October 2013. Two tumors grew back from cells hiding in lymph nodes. I had 12 rounds of FOLFIRI and had the Hipec again October 2014. My lungs and liver are Clea and have been the whole time. I'm 45 years old. I'm hoping this second Hipec gives me relief. I have confidence in the surgeon and specialist. I will continue to follow this thread and also let you know my outcome. It's 3 weeks now after this second Hipec and I'm feeling okay.

I had emergency surgery in April of 2011 for what they though was appendicitis. They found that I had appendix cancer that evidentially ruptured. Strange I never had any pain. The lymph nodes were not involved. I had 6 months of Chemo and was ok for about 2 years. I had a CAT scan in April of 2013 and it was clear but then my CEA rose to 11 later that spring and then I got a PET scan, two spots showed up in the abdomen, one on the ovary and one on the abdomen wall. They were tested and were cancerous. I was referred to University of Pittsburg and had surgery in Sept. 1 of 2013 and HIPEC done. They removed both ovaries, uterus, scraped the abdomen and then removed part of the colon (second time this was done as it was what was done in the initial surgery) and anything else they suspected had tumors growing, then did the heated chemo in the abdomen. There was much cancer there then what showed up in the PET scan. Luckily the liver was not involved. In October 2013, I startede conventional chemo again. My CEA initially was 1 and rose to 3, back to 2 up to 4 and back to 3 where it remained for months. It is now 5 and this worries me a lot. I have otherwise been symptom free with all of my blood work looks good, have no real pain. Have not even had a cold in years. The only problems I have had has been an infected tooth that is currently causing me problems and currently receiving antibiotics for. Dentist thinks the chemo kept my own immune system from getting rid of the infection. After receiving 6 months of IV Chemo, I am now taking Capecitabine and going to infusion every three week for the drug that restricts blood to tumors. I will give you an update on my CEA, as I get them every three weeks.

My husband was dx with low grade, well differentiated mucinous adenocarcinoma of the appendix and PMP in 2010. He underwent debulking in 2011 and had two days of EPIC (5-FU) and one day of radiation. He has remained symptom free to this point, but the tumors are back on his rectum, stomach and small intestine. We were told there is no treatment options available because of the type of tumor and it's slow growth - it would not respond to traditional chemo. However, I notice from the comments that several have had subsequent chemo. Is that an option for the low grade tumors that have recurred? If so, has it been shown to be successful?

Dear Tara, we sent your inquiry to Dr. Nash, and he responded:
“Many cases of recurrent PMP are treated with surgery and/or chemotherapy. However, each case of recurrent PMP has to be looked at individually. Previous treatment is a very important factor, but so is the pattern and location of recurrence and the patient’s overall health. Both surgery and chemotherapy are considered and often used in cases of recurrence; however, it is not possible to make a recommendation for a specific patient without a through history and physical exam, a review of scans, and a discussion of patient’s goals and expectations.”

If your husband would like to make an appointment with one of our specialists for a consultation about his treatment options, please call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

I had Stage pT3a pNO, endometroid adenocarcinoma histologic grade 2 of 3. In 9/14, they removed Uterus and both ovaries followed in Oct -Dec. '14 with chemo (Taxol + Carboplatin every 3 wks. X 6), followed by 5 internal radiations of vaginal cuff. Radiation ended 2/17/15 and chemo ended 1/8/15. A few cancerous nodules were found in pelvic floor, ovaries and one small in omentum. These were removed. Only 2 abdominal lymph nodes were taken but showed negative. A CT with contrast has shown cancer has returned but only in lower pelvic area (clear lungs, liver). Would I be a candidate for the HIPEC? What might you have in a promising study/trial for me?

Dear Martha, we are sorry to hear about your diagnosis. We are currently evaluating HIPEC in women with ovarian cancer, not endometrial or uterine cancer. If you would like to make an appointment to discuss what treatment options and clinical trials may be appropriate for you, please contact our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

This month my mother was diagnosed with Appendiceal Adenocarcinoma, signet ring cell, stage IV.
She had emergent surgery due to colonoscopy complication, perforated viscus, in this surgery the perforated cecum was removed (along with the primary tumor of the appendix) and the surgeons performed a hemicolectomy as well as ileostomy.
She was sent home to recover. I am now attempting to locate specialists in Appendiceal cancer.
I am having a great deal of difficulty obtaining an appointment at MSK.
Any help would be appreciated.
Thank you.

Dear Michele, we’re really sorry to hear about your mom’s diagnosis. We understand our referral specialists have been in touch and an appointment was scheduled. Please do let us know if you need anything else. Wishing you all the best.

I have been diagnosed with cancer of the appendix, sonnet ring cancer and secondary paratneal cancer. I am doing chemo now
Next we will.do CT scan and look for next steps. If I chose surgery what are my chances of survial. 8 am 65 and rel

I had EPIC at MSK back in 2007 for Appendix Cancer that had spread throughout my peritoneal cavity. I had 5 of a planned 8 cycles of IP chemo, followed by systemic chemo (Folfox) and have been healthy since (8+ years since diagnosis.) Question: are they now finding that a single round of EPIC (one 3-day cycle) is sufficient?

Dear Alice, we sent your question to Dr. Nash, who is quoted in this article, and he responded,

“In both retrospective and prospective studies, it is not clear how many cycles of EPIC is optimal. The decision to use a particular number of cycles is made on a case-by-case basis. Many patients are being treated now with a single cycle; however, the option for multiple cycles exists for each patient with a port in place and this may be discussed by the patient with her/his oncologist.”

Thank you for reaching out to us.

I have colon cancer that is in my omentum and a spot on my rectum, I am going to Mayo in Rochester and they had Jacksonville Mayo look at my scan and they said to call them and we'd talk about it, but I'm worried because I don't know their statistics, what are your statistics on prolonged life or any curings for my type of cancer? Do you think it's a good thing? I just turned 50 and really want to see 60+.Thanks

Dear Bridget, we are sorry to hear about your diagnosis. To treat colon cancer that has spread beyond the colon, our compassionate team of specialists use a variety of treatment approaches for metastases — including surgery, image-guided therapies, chemotherapy, biologic therapies, and radiation therapy — to achieve the best possible outcomes for our patients. While statistics offer an overall picture of survival, we don’t recommend applying them to any one individual because everyone’s experience is different and many people do better than expected.

Mayo Clinic has an excellent reputation and we would encourage you to continue asking questions until you feel you have enough information to make a decision around the next steps of your care plan. Thank you for reaching out to us.

I am from Iowa and resently went to Omaha to talk to Dr.Loggie about Hipec for Colon cancer that is in the omentum and at the resection incision, I have been on chemo for a little over a year and so far keeping it in check, I wondered if you feel my doctor is one that could give me the best possible outcome or do you think just doing chemo would be best, I'm only 50 and not anywhere ready to be over,I just want to do what's going to be the best and also be in great surgical hands, Please help.

Dear Bridget, we are not able to make personal medical recommendations on our blog. If you would like to make an appointment with one of our specialists for a second opinion, please contact our Physician Referral Service at 800-225-2225. Thank you for reaching out to us.

Hi..article was written in Nov 2013, what is status of the research or when will results be published?

I was diagnosed w/appendix cancer May 2015. It had metastasized to ovaries. I continue to try to find everything out there on this subject so I can make informed decisions as I partner with my oncologist.

Thanks in advance for your response!

Cheryl, thank you for your comment. MSK investigators are continuing to look at HIPEC and other similar treatments for a number of cancers. We currently have a trial for appendix cancer, in which patients are randomized to either HIPEC or EPIC (postoperative intraperitoneal chemotherapy) after surgery. If you’d like to learn more, you can call 800-525-2225 or for to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment.

My mother is undergoing further tests to try and pinpoint where in the GI her ovarian metastases originated - they believe it's most likely the appendix or small bowel. Is the above mentioned HIPEC or EPIC test still accepting new patients? Does it matter if they are currently covered by Medicaid? I look forward to hearing your response! Thank you in advance.

Lauren, if your mother would like to arrange for a consultation at MSK, she can call 800-525-2225 or go to https://www.mskcc.org/experience/become-patient/appointment for more information on making an appointment. The specialists in our Physician Referral Service will be able to answer your questions about insurance. They can also give you more information on participating in a clinical trial. Thank you for your comment.

I have a friend just diagnosed with peritoneal mesothelioma 2 days ago. he is 22 yo.
How can he make an urgent appointment to be seen and evaluated for possible HIPEC procedure?
Much obliged

My brother has been having fluid buildup in his abdomen and having it drained since Sept. He was seeing a gastro doctor who told him the fluid tested negative for cancer and liver was fine. He finally went to Ochsner in New Orleans and today had camera inserted into abdomen which showed lots of cancer inside. Test results won't come in for a week as to what kind of cancer. It could be mesothelioma or cancer. Would he be considered for the surgery and HIPEC at MSK? He is 67.

Dear Susan, we are sorry to hear about your brother’s diagnosis. We would need to know more about him and his cancer before making a treatment recommendation. If he would like to make an appointment with one of our specialists to discuss possible treatment options and next steps in his care, please ask him to call our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

We are seeing most studies showing Ovarian 1c3 patients with high grade serous carcinomas having 25-45% risk of recurrence, but doctors outside New York told us the risk of recurrence to be 10-20%. Can you give any guidance on the real risk of recurrence? If a stage 1c patients individuals risk of recurrence can be shown to be significantly higher then the stage 1 average, would you ever consider allowing the patient to do IP chemo as either a frontline therapy or a consolidation therapy to try to reduce that risk?

Dear Ken, we sent both of your questions to Dr. Oliver Zivanovic, an MSK medical oncologist who is an expert in HIPEC and specializes in caring for women with ovarian cancer. He responded:

“Depending on clinical trials, histologic subtypes, and sub-stages, the 5-year recurrence-free survival in patients with early stage I ovarian cancer varies between 70% and 90% for those who did receive adjuvant platinum-based intravenous chemotherapy. Prognosis very much depends on histologic subtype (unfortunately, most clinical trials combine all subtypes of ovarian cancer, [i.e., serous, clear cell cancer, and endometrioid] into their analysis) and also whether or not an optimal staging procedure was performed (adequate lymph node sampling and peritoneal sampling). Now with new data emerging that weekly paclitaxel may be as effective as Intravenous (IV) plus IP chemotherapy, and given the higher toxicity profile associated with IP treatment, we would not recommend IP treatment in the setting of optimally staged FIGO stage IC serous carcinoma.

The role of HIPEC in the treatment of ovarian cancer is not yet established. We would not recommend this as consolidation treatment in the setting of early stage disease as there is no data to date to suggest that there is a benefit.”

We hope this information is useful. If you would like to make an appointment for a loved one to consult with one of our specialists about possible treatment options, please contact our Physician Referral Service at 800-525-2225. Thank you for reaching out to us.

Oops- i sent an genral ip question to this site by mistake. I do have a hipec question i could ask. Do you ever do hipec without CRS as a consolidation therapy? If so, how would the risks compare to 4 cycles of IP?

Thank you so much for the help. We heard that testing high risk early stage for benefit of IP and it's variants isn't practicable, so two armed evidence will never exist (although a retrospective study, Furiwara, had a 95% nonrecurrence).

I understand IP/HIPEC works best cytoreduced to no visible disease. Would you expect the weekly paclitaxol to be as effective IP given she is completely cytoreduced? For my wife, given the high grade epilthilial carcinoma, if the 1/3 recurrence occurs, will it be likely to be cytoreducable to the point she is now?

We are looking at coming to MSK between the third and fourth cycle (that's what scheduling told us to do).

Many many thanks,


Dear Ken, we recommend you and your wife discuss this with the MSK physician at your upcoming appointment. He or she will be best equipped to give you more specific information regarding her particular treatment plan. Thank you for reaching out to us.

Do they know the potential risks of EPIC yet in an appendix cancer patient? Do they also have any information at all concluding that this is helpful?