Aug. 5, 2015 -- Almost a decade ago, the National Cancer Institute alerted doctors that a treatment that could extend the lives of women with advanced ovarian cancer was not being used often enough.
The announcement was supposed to make the treatment, called intraperitoneal chemotherapy or IP, more widely available.
A new study shows that hasn’t happened, though.
The study of 823 ovarian cancer patients treated at six specialty cancer centers found that fewer than half of women eligible for IP chemotherapy received it between 2006, the year the NCI issued the alert, and 2012.
What’s more, use of the treatment varied greatly, with some centers reporting rates of IP as low as 4% and as high as 67%.
IP chemo involves pumping drugs toxic to tumors directly into the abdominal cavity, along with delivering them through a vein. The idea is that soaking internal organs in the potent medications, and delivering them through the blood, packs a one-two punch to slow or stop aggressive cancers.
Why Isn't the Treatment Used More?
“It’s depressing,” says Barbara Ann Goff, MD, director of the Division of Gynecologic Oncology at the Fred Hutchinson Cancer Center in Seattle. She was not involved in the study. “These very vulnerable women are not being treated according to what we know is going to give them the best chance of cure.”
About 22,000 women are diagnosed with ovarian cancer in the U.S. each year. In nearly two-thirds of women, the disease has already spread beyond the ovaries by the time it’s found, lowering their chances of survival. Only 27% of women who are diagnosed after their cancer has spread will survive for 5 years, according to data collected by the National Cancer Institute.
“Doctors think women with ovarian cancer are going to die no matter what you do, so why put them through something that’s toxic?” Goff says.
People who get IP chemotherapy do have more short-term side effects like diarrhea, nausea, vomiting, and pain compared to people who only get standard chemotherapy, but research shows they also live longer.
A study that followed women with ovarian cancer for 10 years found that those who got IP chemo lived about a year longer than those who were only treated with standard chemo, and they had a 23% greater chance of survival.
“It’s disappointing that more patients aren’t receiving a therapy that’s clearly been shown to be of benefit,” says the study’s senior author, David O’Malley, MD, a gynecologic oncologist at The Ohio State University Wexner Medical Center, which was one of the hospitals in the study.
At Ohio State, 93% of patients were offered IP. But only 52% of women ultimately got the treatment.
“Even at our own institution, there’s much room for improvement,” O’Malley says.
Part of the trouble, he says, is that IP chemo takes more time. Patients need to visit the hospital two or three times every 3 weeks, instead of just once as they would with standard chemotherapy.
But beyond the inconvenience, O’Malley thinks a bigger factor may be how patients are educated by their doctors and how patients, in turn, respond to the information they receive.
O’Malley says he believes many doctors are unfairly biased against IP, and it shades the way they describe it to their patients.
Ohio State and five other centers are currently testing an iPad app to see if it might do a better job of helping women make informed choices about their own care.
“It’s giving patients a tablet and asking them what weight they would give, you know, living longer versus a higher risk of neuropathy (nerve pain), and a score is being generated kind of making a recommendation,” O’Malley says. “We’re attempting to remove some of the bias.”
But doctors' biases aren’t the only reason IP chemo isn’t used as often as it could be.
Expert: It's a 'More Challenging' Treatment
When Stephanie Blank, MD, was a medical resident, she enrolled women in trials of IP therapy. She still remembers one patient’s reaction.
“She had one cycle and she said, ‘Chemotherapy is so awful, I’m not getting anything.' And she had no chemotherapy at all after that,” says Blank, who is now an associate professor of gynecologic oncology at the New York University School of Medicine.
But Blank says that over time, doctors have successfully tinkered with how they give IP treatments, changing up the drugs and the ways they are delivered in ways that have made it easier for patients to tolerate.
Blank says she offers IP chemo as a frontline treatment to any patient who would be a good candidate for it -- and she says it's sometimes a tough sell.
“Regular chemotherapy is difficult, and this is a more challenging regimen to get through,” says Blank, who also serves on the board of directors for SHARE, a nonprofit that helps with women breast and ovarian cancer. “If someone is extremely fearful of chemotherapy, this is not chemotherapy lite, by any measure.”
When patients turn her down, she often tries to talk them through their fears, because she knows the treatment is so effective.
“We just promise them that we’ll listen to what they say and we’ll adjust things if need be,” she says.