Read an interview with Dr. Valerie Francescutti (formerly of Roswell Park), Surgical Oncologist in the Soft Tissue Sarcoma/Melanoma Division at Roswell Park Comprehensive Cancer Center (Roswell Park), about the benefits of this advanced procedure and her research into why few patients are referred for the possibly life-extending treatment.
Q: What treatment options are available for patients that have peritoneal metastases or carcinomatosis?
A: In the past, carcinomatosis was treated with systemic chemotherapy, with surgery for palliative purposes. More recently, cytoreduction or surgical removal of all visible tumor nodules in the abdominal cavity, followed by hyperthermic intraperitoneal chemotherapy (HIPEC), has become an option. This procedure may be beneficial as part of the management of patients with cancers originating in the appendix such as pseudomyxoma peritoneii [also known as disseminated peritoneal adenomucinosis (DPAM), or peritoneal mucinous adenocarcinoma (PMCA)], gastrointestinal primary cancers such as colorectal cancer, and peritoneal mesothelioma. Both at Roswell Park Cancer Institute and elsewhere, cytoreduction/HIPEC has had a meaningful impact on the survival rates of these patients. The increase in clinical interest and ongoing research has made patients and families better aware of this as a treatment option. When this procedure is utilized as part of a larger treatment strategy, patients can often be able to be off of systemic chemotherapy where in the past continuous palliative systemic chemotherapy was offered.
Q: Since cancer centers that have the ability to provide this treatment have seen such a positive response, why wouldn’t all patients with carcinomatosis be referred for this treatment?
A: Roswell Park has a well-established cytoreduction/HIPEC program, with three surgeons (Drs. John Kane, Joseph Skitzki and Valerie Francescutti) providing consultation and surgical procedures. However, this procedure is not available at every center, given the required infrastructure, and expertise in surgical management and postoperative care. Roswell Park is the only center in Western New York offering cytoreduction/HIPEC. Also, not all patients are appropriate candidates for the procedure. We spend a great deal of time ensuring we have reviewed all of the patient’s information at a first visit and have a thorough discussion with the patient regarding risks and benefits. Patients that are in good physical health who can tolerate the stresses of a surgical procedure and the associated recovery are considered the best candidates. Therefore, the elderly or those with multiple comorbidities and health problems are generally not good candidates.
Regarding the types of tumors best treated by this approach, DPAM (previously termed pseudomyxoma peritonei), is not sensitive to systemic chemotherapy and therefore is generally well treated with cytoreduction/HIPEC. For other more aggressive cancers such as appendiceal adenocarcinoma and colorectal cancer, where systemic chemotherapy is also beneficial, patients that are best suited to the cytoreduction/HIPEC procedure are those that do not have any hematogenous metastatic disease (liver, lung or distant nodal metastases), or those that have had the distant metastatic disease treated with no recurrence. Additionally, those that have a lower abdominal tumor burden of carcinomatosis (termed the “peritoneal carcinomatosis index”) are better treated with cytoreduction/HIPEC than those with higher burden, or unresectable disease.
Q: Do you have any ongoing research regarding the cytoreduction/HIPEC procedure at Roswell Park?
A: My clinical research in cytoreduction/HIPEC is a very comprehensive evaluation of the patient experience of those choosing to undergo the procedure. The preoperative work up, the hospital stay and the post operative recovery can be challenging. For most patients, this can result in modifications and changes to responsibilities, family dynamics and other factors. To develop a program to help patients prepare and participate in the preoperative planning and the in-hospital and at-home recovery, we are actively interviewing patients that have recently undergone the procedure to understand the important factors that would help to prepare and educate them.
Q: How will your research address these possible issues?
A: Our plan is to initially develop a program for patients that will involve preoperative education and preconditioning including nutrition and physical therapy, as well as other education as necessary (ostomy management). The in-hospital and post-operative recovery program will involve a similar parallel program where we will empower caregivers with hands-on teaching and information to assist with the recovery process. We also hope to identify important survivorship issues specific to this procedure for ongoing future educational programs.