Mother pegs hopes on chemo bath

Canton Township

The night before Joanne Savage had surgery to remove a rare cancer, she was tucking her three sons into bed. Before she kissed her oldest boy goodnight, he wanted to know more about her operation.

"Am I going to have to grow up without a mom?" asked the boy, then 10.

Her son's fear is one reason Savage became the first patient to undergo an operation in Michigan that sounds almost like science fiction. Her abdomen was sliced open by a surgeon, who removed scores of tumors from her organs before a machine pumped heated chemotherapy through her torso for almost two hours. The surgery took 14 hours and required a two-week hospital stay at St. John Providence Health System, the only place in Michigan to offer it.

Known among patients as a chemo bath, the procedure was first used to destroy rare cancers that have spread to the abdominal lining. But its use is growing to include more common cancers, such as colon and ovarian, and that has created controversy.

Proponents say it gives alternatives and longer prognoses to patients battling certain cancers. But critics counter it is being done before enough clinical trials have shown this is the best treatment, and it is reminiscent of painful cancer treatments used in the past that studies later showed were not necessary.

For Savage, 46, the surgery was a godsend since her husband, Pat, was diagnosed with Stage 4 esophageal cancer a few days before. He died earlier this month.

"If I hadn't taken care of it, my children would have been without a mom, too," said Savage of Canton Township.

It took several doctors and many diagnoses before Savage learned in October 2007 that she had pseudomyxoma peritonei — a rare disease that originated with cancer in her appendix and then spread to her abdominal cavity.

The mucus-like cancer was growing on the exterior of her organs, so traditional chemotherapy wouldn't work, doctors told her. A University of Michigan doctor told her the cancer was incurable but that it could be managed with an operation that involved scraping the cancer off the organs.

Savage underwent that surgery in December 2007, but the cancer returned 3 1/2 years later. This time, her U-M doctor told her she needed to have a chemo bath, formally known as Hyperthermic Intraperitoneal Chemotherapy — or HIPEC.

"I went on the Internet, saw videos, threw up," Savage said. "It was very, very scary."

Without it, doctors said Savage would have had only a few years to live.

She was referred to a hospital in Pittsburgh. But it didn't take her insurance to cover the cost of the surgery. Other hospitals outside of Michigan that offered the procedure also wouldn't take her insurance.

Offered in Detroit

Around that time she found Dr. Richard Berri, a surgical oncologist who was offering the procedure at St. John Hospital & Medical Center in Detroit.

Berri said the surgery is for patients who have primary cancer — either cancer of the appendix, colon or rectum, stomach, ovaries or primary cancer of the peritoneal cavity — that have spread to the lining of the abdomen. Once that occurs, it is considered a Stage 4 disease — and the median prognosis is between three and seven months survival, Berri said.

In the past, these patients were not offered much treatment. Sometimes, they were offered chemotherapy, but not surgery.

Recently, some surgeons have turned to the surgery that begins with removal of hundreds of tumor sites in the abdomen and, if necessary, removal of organs not required for survival. Then, a machine is used that heats and pumps chemotherapy mixed with a solution directly into the abdomen for about 90 minutes.

"The theory is the heat will increase the toxicity of the chemotherapy and will allow the chemo to penetrate all the tissues better," said Berri, who has done the procedure on three other patients. "Since the chemotherapy is directly on the surface of the organs and any residual microscopic tumors left behind, it had a lethal effect on the cancer."

Not a 'miracle procedure'

The first HIPEC treatment was done during the early 1980s, according to Dr. Paul H. Sugarbaker, a surgeon at Washington Hospital Center in Washington, D.C. It was done on a patient with the same disease Savage had, and many people have since survived 20 years, he said.

"This combined treatment of removing all the visible disease with surgery and then washing in the operating room with chemotherapy … it gives us a cure," said Sugarbaker, who is considered to be a pioneer of the treatment.

"In the past, this surgery … was used last-ditch, when nothing else was helping because the less-aggressive treatment would be chemotherapy into the vein," Sugarbaker said, adding it is now used more often when cancers are caught earlier.

Dr. Marwan Fakih, a U-M oncologist, said he doesn't think HIPEC is a "miracle procedure" because studies thus far have been predominantly in one health center — as opposed to several — and without a control group to compare results.

But he said it is an option that should be discussed for select patients.

"It's always good to have procedures that can be used wisely in a select patient population," Fakih said.

Critics such as Barron Lerner, a professor of medicine and public health at Columbia University Medical Center, said data for HIPEC success on the rarer cancers have led to "enthusiastic assumptions that results would be comparable in other much more common cancers without enough data being out there."

Additionally, he said, procedures such as this can be profitable and might be attractive to certain physicians and medical centers as a way to attract patients.

Best HIPEC debated

Lerner said the HIPEC procedure reminds him of the very aggressive surgery done during the 1950s and 1960s for breast cancer patients, who underwent surgery that sometimes removed ribcages, sternums and even limbs.

"The philosophy behind this was if we can get rid of all the cancer cells in the body, we can cure this person," Lerner said, "so we are going to be very aggressive. Despite these well-meaning attempts, they really didn't prolong survival for patients, and they may have caused a lot of suffering along the way and even led to premature death."

Proponents counter that more clinical trials are under way, and success with the surgery has improved.

When the operations were first done, 30 percent to 50 percent of patients suffered major surgical complications, and there was a 2 percent mortality rate. Now, the complication rate has shrunk to 10 percent, and the mortality rate is less than 1 percent, Sugarbaker said.

Sugarbaker acknowledged there are still some problems as the most effective HIPEC isn't known. Many different types of chemotherapy are being used, along with different amounts of heat.

Additionally, in about half of the patients, the treatment doesn't work.

"We need a more perfect HIPEC," Sugarbaker said. "The other thing we need is we need to treat the disease earlier. But we're getting there."

Despite the problems, many doctors said prognosis is dramatically better for most patients.

Compared with just a few-month prognosis without the surgery, many patients say they will take it.

"Things happen for a reason," Savage said. "I really believe God has a plan for all of us."

kkozlowski@detnews.com

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