Advanced Ovarian Cancer Treatment: Beyond Surgical Debulking to Complete Cytoreduction

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• The Problem with Tumor Debulking in Ovarian Cancer
• Optimal Surgical Approach: Meticulous Cytoreduction
• Role of HIPEC in Ovarian Cancer Treatment
• Long-Term Intraperitoneal Chemotherapy (BANC)
• Patient Selection for Aggressive Treatment
• How Patients Can Seek the Best Care
• Full Transcript

The Problem with Tumor Debulking in Ovarian Cancer

Dr. Paul Sugarbaker, MD, identifies a critical flaw in the current standard surgical care for ovarian cancer. The common practice of tumor debulking involves removing only a portion of the visible cancer. Surgeons then rely on systemic chemotherapy to eradicate the remaining tumor cells left behind.

Dr. Sugarbaker calls this a "bad concept." He emphasizes that while ovarian cancer is more chemotherapy-sensitive than some gastrointestinal cancers, leaving macroscopic disease behind is a suboptimal strategy. This approach fails to capitalize on the potential for a complete surgical cure and can compromise long-term survival outcomes for patients.

Optimal Surgical Approach: Meticulous Cytoreduction

The gold standard for advanced ovarian cancer surgery, according to Dr. Paul Sugarbaker, MD, is complete cytoreduction. This procedure involves peritonectomy and necessary visceral resections to eliminate every visible sign of cancer within the abdominal cavity. The surgical goal is to achieve a state of no visible evidence of disease.

This meticulous and often radical surgery is the first and most crucial step in improving ovarian cancer treatment results. Dr. Paul Sugarbaker, MD, states that these principles, which are standard for treating peritoneal mesothelioma, are not yet widely adopted for ovarian cancer. He believes implementing this aggressive surgical standard is the primary way to advance patient care and survival rates.

Role of HIPEC in Ovarian Cancer Treatment

Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a vital component of modern ovarian cancer treatment. This procedure involves bathing the abdominal cavity with heated chemotherapy drugs immediately after cytoreductive surgery. The heat enhances the penetration and effectiveness of the chemotherapy against any microscopic residual cancer cells.

Dr. Paul Sugarbaker, MD, references a key randomized controlled trial that demonstrated a significant benefit. Patients with recurrent ovarian cancer who received cytoreductive surgery combined with HIPEC had better outcomes than those who had surgery alone. This evidence supports the integration of HIPEC into the multimodal treatment plan for suitable candidates.

Long-Term Intraperitoneal Chemotherapy (BANC)

Dr. Paul Sugarbaker, MD, advocates for an extended chemotherapy regimen following surgery and HIPEC. This approach is called Bi-directional Adjuvant Normothermic Chemotherapy (BANC). BANC involves the long-term administration of chemotherapy directly into the peritoneal space, usually for six months, in combination with systemic intravenous chemotherapy.

A key medication in this regimen is paclitaxel (Taxol). Dr. Paul Sugarbaker, MD, explains that paclitaxel is a "wonder medication" for intraperitoneal use because it remains in the abdominal cavity for extended periods—up to 23 hours. This prolonged exposure provides a continuous assault on microscopic cancer cells, far exceeding the brief duration of the HIPEC procedure itself.

Patient Selection for Aggressive Treatment

Dr. Paul Sugarbaker, MD, stresses that this aggressive multimodal treatment is not appropriate for every patient. Careful patient selection is paramount to achieving success and avoiding harm. Factors like a patient's age, overall fitness, and ability to tolerate an extensive 8-hour surgery must be thoroughly evaluated.

The goal is to avoid performing a massive operation on a patient who may not survive the procedure or who may never recover a reasonable quality of life. The treatment is best suited for patients who are physically robust enough to withstand the rigors of cytoreduction, HIPEC, and the subsequent months of combination chemotherapy.

How Patients Can Seek the Best Care

Dr. Anton Titov, MD, and Dr. Paul Sugarbaker, MD, agree that patients must be proactive in their care. Individuals diagnosed with ovarian cancer should actively seek out a surgical oncologist who is willing and skilled in performing radical cytoreductive surgery. This often means looking beyond local standard practices to find a specialist at a high-volume center.

Dr. Sugarbaker is convinced that adopting this comprehensive method—complete cytoreduction, HIPEC, and BANC—will lead to better treatment results worldwide. Patients may have two ports placed: one for intravenous chemotherapy and another specifically for the administration of long-term intraperitoneal chemotherapy, facilitating this intensive treatment protocol.

Full Transcript

Dr. Anton Titov, MD: Renowned Harvard-trained American cancer surgeon discusses common problems with ovarian cancer surgical treatment. Surgeons and oncologists must treat ovarian cancer more aggressively and more meticulously than they often do. "Debulking of ovarian cancer tumor is a bad concept in ovarian cancer treatment." What is BANC, Bi-directional Adjuvant Normothermic Chemotherapy? Ovarian cancer best treatment options.

Dr. Paul Sugarbaker, MD: Ovarian cancer surgery should be more aggressive. Best cancer surgeon for ovarian cancer must remove all signs of cancer cells in the abdomen and in the peritoneum. Ovarian cancer surgery today in many places is not adequate. Debulking of ovarian cancer tumor is not enough.

Ovarian cancer patients should have meticulous cytoreduction with peritonectomy and visceral resections until there is no visible evidence of ovarian cancer. Ovarian cancer spreads in the abdomen and peritoneal cavity.

Dr. Anton Titov, MD: Peritoneal metastases in advanced stage 4 ovarian cancer treatment by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) [hot chemo bath, heated chemotherapy]. Medical second opinion clarifies ovarian cancer diagnosis. Medical second opinion confirms that cure is possible in metastatic ovarian cancer.

Intraperitoneal chemotherapy treatment for advanced stage 4 ovarian cancer with metastatic lesions in the abdomen. Medical second opinion helps to select a precision medicine treatment for stage 4 ovarian cancer.

Get medical second opinion on advanced ovarian cancer with peritoneal metastases. Best peritoneal metastatic advanced cancer treatment by surgical operation and regional chemotherapy. Video interview with Dr. Paul Sugarbaker, leading expert in peritoneal metastatic cancer treatment (cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC), hot chemo bath, heated chemotherapy.

Ovarian cancer best treatment options. Best doctor for ovarian cancer treatment.

Dr. Anton Titov, MD: Ovarian cancer affects 1 in 70 women. But those who have BRCA1 and BRCA2 mutations have much higher incidence of ovarian cancer. There are well-publicized ovarian cancer situations.

Daughter of Pierce Brosnan (famous actor) and his wife passed away from ovarian cancer. Pierce Brosnan's daughter died from ovarian cancer at the young age of 42. Angelina Jolie's mother at 56 died from ovarian cancer. Ovarian cancer is a very important disease for younger people.

Peritoneal metastases in ovarian cancer are quite frequent. How do you treat patients with ovarian cancer and peritoneal metastases from ovarian cancer?

You also published studies showing that some patients with ovarian cancer have lower malignant potential of ovarian cancer cells. Different malignant potential of ovarian cancer cells also affects selection of ovarian cancer patients with peritoneal metastatic disease for appropriate treatment. Treatment of ovarian cancer by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Could you please comment on the ovarian cancer treatment in your hands?

Dr. Paul Sugarbaker, MD: Ovarian cancer treatment by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) is a work in progress. There is now a single randomized controlled study of ovarian cancer treatment. It shows that patients with recurrent ovarian cancer do better if they have cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Ovarian cancer patients did better when cytoreductive surgery was combined with HIPEC than when cytoreductive surgery alone was used to treat ovarian cancer. This is a very important study.

There are 4 randomized controlled clinical trials on ovarian cancer treatment currently active. These clinical trials in ovarian cancer ask this question.

Dr. Anton Titov, MD: Should cytoreductive surgery alone be used to treat ovarian cancer? Or should cytoreductive surgery be combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC)? Ovarian cancer treatment by Hyperthermic Intraperitoneal Chemotherapy (HIPEC) in addition to cytoreductive surgery to resect ovarian cancer metastases in the peritoneal space?

Dr. Paul Sugarbaker, MD: Yes. Here is what I would say about ovarian cancer surgery at this point in time. Today the concept of ovarian cancer treatment by surgery is tumor debulking. This is the standard of care for most surgeons performing ovarian cancer treatment by surgical operation.

"Debulking" is removal of some but not all tumor. Surgeons just remove some ovarian cancer tumor. They expect the systemic chemotherapy to kill the rest of ovarian cancer tumor cells.

It is true that chemotherapy in ovarian cancer is quite effective. Chemotherapy in ovarian cancer is more effective than chemotherapy of gastrointestinal cancer. But current treatment standard of surgical debulking of ovarian cancer is a bad concept. It is a bad concept.

Ovarian cancer patients should have the same meticulous cytoreduction with peritonectomy and visceral resections until there is no visible evidence of disease. Ovarian cancer patients should have a radical resection of all visible cancer. This is what we would have for peritoneal mesothelioma.

That is not happening at this point. Radical surgical resection of all ovarian cancer tumor is the first and biggest step in the improved treatment of ovarian cancer. The goal is to bring these surgical oncology principles of peritoneal cavity cancer treatment into treatment of all patients with ovarian cancer.

Primary ovarian cancer or recurrent ovarian cancer deserve best surgical treatment.

Dr. Anton Titov, MD: At the moment it is not happening. More patients with ovarian cancer should have better surgical resection of ovarian tumors?

Dr. Paul Sugarbaker, MD: No, no, it is not a current standard of care for ovarian cancer. At this point in time only a small number of ovarian cancer patients have this treatment. It is very meticulous surgery to remove all ovarian cancer tumor spread from peritoneum.

Some of ovarian cancer patients are older women. They are not so fit. It is not appropriate to put them through 8 hour long surgical procedure, cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC).

Of course, you have to be selective in which ovarian cancer patient to take for radical resection of ovarian cancer. It doesn't pay to do a big ovarian cancer operation on someone, then have them die after surgery.

It is not appropriate to do such an extensive surgery (ovarian cancer cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC)) that they can never recover a reasonable quality of life. You have to be selective, of course.

Dr. Anton Titov, MD: But the first step in improving the results of ovarian cancer treatment is this. Surgeon has to use peritonectomy with visceral resection to remove all visible evidence of ovarian cancer disease.

Dr. Paul Sugarbaker, MD: My best recommendation for the treatment of patients with ovarian cancer at this point in time is this. It is the meticulous and complete cytoreductive surgery combined with Hyperthermic Intraperitoneal Chemotherapy (HIPEC). Also long-term ovarian cancer intraperitoneal chemotherapy should be added to cytoreductive surgery and HIPEC.

We call such ovarian cancer long-term intraperitoneal chemotherapy BANC, Bi-directional Adjuvant Normothermic Chemotherapy. After the best intra-operative treatments the ovarian cancer patient has combined intraperitoneal and systemic chemotherapy usually for six months to treat ovarian cancer.

For long-term intraperitoneal chemotherapy of ovarian cancer a combination of medications is used. Usually it is cisplatin, carboplatin and taxol. Taxol is paclitaxel.

Paclitaxel is somewhat of a wonder medication in intraperitoneal chemotherapy of ovarian cancer. Paclitaxel (Taxol) is from a pharmacologic perspective the medication that is most likely to be effective in intraperitoneal chemotherapy of ovarian cancer.

Paclitaxel (Taxol) remains within the peritoneal space for a long time. Paclitaxel does not have 60 min or 90 min activity while Hyperthermic Intraperitoneal Chemotherapy (HIPEC) takes place in abdomen of ovarian cancer patient. Taxol (paclitaxel) will have a 23 hour out of 24 hours that Paclitaxel remains in the abdominal cavity of ovarian cancer patient.

Dr. Anton Titov, MD: Patients with ovarian cancer should really take initiative. Ovarian cancer patients should seek a surgeon who is willing to be more radical in treatment of ovarian cancer. Ovarian cancer patients should look for surgeon who has better skills in radical cytoreductive surgery in ovarian cancer.

This may lead to better ovarian cancer treatment results for patients around the world.

Dr. Paul Sugarbaker, MD: Yes. I am convinced that this method will bring better ovarian cancer treatment results. It is cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) followed by long term intraperitoneal chemotherapy.

Ovarian cancer patients will often have two ports. One port for administering intravenous chemotherapy. Then another port for administering long-term intraperitoneal chemotherapy to treat ovarian cancer better.

Dr. Anton Titov, MD: Leading cancer surgeon speaks about frequently inadequate treatment of ovarian cancer.