Advancing Peritoneal Mesothelioma Treatment
April 7, 2021
The most effective treatment today for malignant peritoneal mesothelioma involves cytoreductive surgery and hyperthermic intraperitoneal chemotherapy (HIPEC). Early postoperative and long-term regional chemotherapy follows surgery.
This is the regimen where “cured” becomes an option. It’s a major advance – a game changer – for a very rare disease. It becomes the answer to the peritoneal mesothelioma problem.
Our record at the Washington Cancer Institute at MedStar Washington Hospital has been impressive, but I don’t think anyone else in this country is using our routine or attempting to duplicate our results.
The task now is getting out the word and convincing those trying to treat this rare cancer of what works best. I’ve included the details in my paper, which will be published in Annals of Surgical Oncology.
The manuscript includes some practice-changing content. In it, we create the rationale for this prolonged intraperitoneal chemotherapy for a very unique disease.
Unprecedented Treatment Success
It’s something that anyone interested in peritoneal mesothelioma would at least want to consider. Trying to sell something new to the surgical oncology community isn’t always easy. This will be worth the effort, though, because of the difference it could make for these patients and their mesothelioma prognosis.
I’m proud of what we’ve accomplished here. We are seeing 75% of the patients alive and well at 10 years. That was unheard of a decade ago.
In our latest propensity matching study we had one group of 36 patients, and it looks now like 75% of them are cured.
Unfortunately, that kind of success is not being repeated elsewhere like it could be. The expertise is not getting to most patients around the country. That needs to change. In too many places, patients with peritoneal mesothelioma are getting less than optimal care.
When I hear the stories, I feel like getting up and giving a speech, presenting my data, the rationale for how we treat patients – and the results. Too many centers are only interested in their institutional protocol. Their patients suffer.
You’ve heard the saying, if the only tool in the box is a hammer, then all the world is a nail. A medical oncologist, if his only tool is to give drugs into the vein, that’s what he’s going to do, hitting the body again and again with drugs into the vein. Some of it will get to the peritoneal space, but not nearly as efficiently as if it’s given directly into the peritoneal space.
Systemic chemotherapy for peritoneal mesothelioma, which is still being done in some places, does not prolong survival. You get a response, but it is not durable. Nobody with this disease lives longer because of systemic chemotherapy.
This is a unique disease, and it must be treated that way.
Changing Mesothelioma Surgery Procedures
Many today are using cytoreductive surgery and HIPEC, but trying to treat this disease with one surgery and one intraperitoneal chemotherapy session isn’t enough anymore.
It might make a big difference in a subset of patients, the kind of super responders, but it’s not the best answer to the disease today.
Following surgery, which can take 10-12 hours, and a 90-minute HIPEC procedure, we leave the catheters behind. For six consecutive days then, chemotherapy is circulated through the peritoneal cavity and removed. We call it EPIC, for early postoperative intraperitoneal chemotherapy.
Next comes NIPEC, normothermic intraperitoneal chemotherapy, a long-term regional treatment delivered through an implanted intraperitoneal port. It works well.
The NIPEC procedure in our trial began four to six weeks postoperatively for patients and included six cycles separated by three weeks.
In a disease process where 90% of the mortality comes from progression within the peritoneal space, this routine seems to work. With some cancers, regional chemotherapy doesn’t show a real advantage. With peritoneal mesothelioma, it really does, particularly repeated installations.
In our study, the five-year survival rate went from 50% for those in the control group to more than 75% for those receiving the NIPEC. It is also used now with gastric cancer and the peritoneal metastases that occur with this disease. For those, it is working well.
The next step would be to publish the treatment protocol. It will take a major commitment for others to follow, which is why centralizing treatment for this disease might be the best way to go.
If others can duplicate the success that we’ve had, everyone will benefit. It will change the way people look at this disease, and the way it is treated.