Special delivery
Drugs given via catheter into the abdomen increase survival in women with ovarian cancer
By Richard Saltus
Dianne LaBounty works on a scrapbook at home after completing IP Therapy.
When retired schoolteacher Dianne LaBounty was diagnosed with advanced ovarian cancer last year, she was fortunate in one respect. Just months earlier, a clinical trial had proven the value of an aggressive treatment for her disease that had long been controversial.
Signaling that the debate was over, the National Cancer Institute declared that intraperitoneal (IP) chemotherapy, which had strikingly improved the survival of patients in the study, was now the preferred option for women in LaBounty's situation.
The standard treatment for advanced ovarian cancer has been surgical removal of the ovaries and uterus and as much visible cancer as possible — a procedure called "debulking" — followed by six cycles of intravenous chemotherapy with cisplatin and Taxol (paclitaxel). For several decades, some physicians had advocated attacking the residual cancer more directly by administering high doses of the drugs through a catheter placed into the abdominal cavity, or peritoneum. Intraperitoneal therapy wasn't widely accepted prior to the study reported in the New England Journal of Medicine in January 2006, which showed that women treated with IP therapy lived, on average, a year longer than those who had the standard intravenous treatment.
"It is a very significant improvement in survival," says Ursula Matulonis, MD, director of Gynecologic Oncology at Dana-Farber. "Since the study was published, many women have opted for IP therapy because of the survival benefit."
When presented with the alternatives, LaBounty says, "The team said they recommended this more-aggressive treatment, and at first, I was petrified." The higher doses used in IP delivery often cause harsher side effects, which are explained in extensive literature provided to patients. "But I talked it over with my husband and with my doctor who had originally diagnosed my cancer, and now I'm so thankful that I did it."
Chemotherapy is administered through a catheter implanted temporarily into the abdomen.
Illustration by Irina Zlobina
"I thought I'd be sick all the time," adds LaBounty, "But overall it wasn't as bad as I'd thought it would be." She and other IP patients have benefited from improved antinausea drugs given "up front" to forestall vomiting, and also from the special training of nurses on the IP team, which includes physicians, nurses, physician assistants, nurse practitioners, and social workers.
Still, not all women with advanced ovarian cancer are good candidates for the rigorous IP regimen, which can cause lowered blood cell counts, dehydration, and numbness and tingling in the hands and feet. "They have to be motivated, healthy, and have good kidney function and no serious uncontrolled medical problems," explains Dr. Matulonis. Though younger women tend to be more resilient, older age is not in itself a barrier. So far, few women offered the IP option have turned it down. "Most are driven by the better outcomes of this therapy," she says.
For a patient to be eligible, surgeons must succeed in removing all visible tumors, leaving no malignant tissue larger than one centimeter in diameter; this can be accomplished in about 75 percent of surgeries. After a recovery period, the patient begins six 21-day-cycles of combined IP and IV chemotherapy, each cycle starting with a three-day admission to a room in a dedicated inpatient unit at Brigham and Women's Hospital (BWH). As a first step, surgeons implant a round metal access port in the skin beneath the rib cage, with a narrow, flexible plastic catheter that extends into the abdomen. The device remains in place for the duration of the therapy.
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