Practice patterns, attitudes, and knowledge among physicians regarding cytoreductive surgery and HIPEC for patients with peritoneal metastases

Our plain-English summary of Practice patterns, attitudes, and knowledge among physicians regarding cytoreductive surgery and HIPEC for patients with peritoneal metastases, by T. Bernaiche, E. Emery, L. Bijelic (Pleura and Peritoneum, 2018).

The study

• Authors: T. Bernaiche, E. Emery, L. Bijelic
• Journal: Pleura and Peritoneum
• Published: 2018;3(1):20170025
• Cited by: 20 articles, as counted by NIH iCite
• Read it: PubMed · Publisher · Free full text

Abstract

Background: Cytoreductive surgery (CRS) and heated intraperitoneal chemotherapy (HIPEC) is a treatment option for patients with peritoneal metastases shown to provide improved overall survival for appropriately selected patients. However, the availability and utilization of this treatment remains limited. The aim of this survey-based study was to evaluate factors influencing physician treatment choices for peritoneal metastases.

Methods: Surveys were mailed to medical oncologists and surgeons in Virginia, Maryland, and Washington, D.C. Survey questions evaluated access to HIPEC centers, prior experience with referral to HIPEC centers, opinions regarding efficacy, and knowledge regarding outcomes of CRS and HIPEC.

Results: Surveys were mailed to 2279 physicians; 116 eligible surveys were returned. Seventy-five percent of respondents would consider referral to a HIPEC center for appendiceal peritoneal metastasis, while only 50% would consider it for colon cancer and peritoneal mesothelioma. The most common reason for never referring a patient to a HIPEC center was lack of access to a HIPEC specialist (47%) followed by perceived lack of evidence for the treatment modality (31%). Five-year survival after CRS and HIPEC was underestimated while 30-day mortality was overestimated by more than half of respondents.

Conclusions: Referral to HIPEC centers is underutilized among community physicians in practice. Limited access to HIPEC experts is the most common cause for lack of referral, followed by a perception of insufficient evidence for this treatment approach. Lack of familiarity with data regarding outcomes impacts referral patterns and treatment choices. Possible actions to increase awareness and appropriate utilization of CRS and HIPEC are suggested.

In plain English

This mailed survey covered general surgeons and medical oncologists in Virginia, Maryland and Washington, D.C. It asked about cytoreductive surgery with heated intraperitoneal chemotherapy (CRS and HIPEC), a treatment for cancer that has spread to the lining of the abdomen and for peritoneal mesothelioma. It did not study asbestos exposure. Of 2279 surveys mailed, the authors analyzed 116 eligible surveys from doctors who treat gastrointestinal cancer. Most respondents (79.3%) were general surgeons. Seventy-five percent would consider referral to a HIPEC center for appendiceal cancer spread to the peritoneum, and 50% for colon cancer and peritoneal mesothelioma. Among respondents who had never referred a patient, 46.9% cited lack of access to a HIPEC specialist and 31.3% a perceived lack of evidence. Two thirds of respondents (66 of 100) underestimated five-year overall survival after CRS and HIPEC in an experienced center for peritoneal mesothelioma. Most respondents overestimated 30-day mortality compared with results from experienced centers. The authors concluded that referral to HIPEC centers is underused among community physicians. They named the low response rate (11%) as the main limitation.

We wrote this plain-English summary from the full article with the help of AI, and a second AI model checked each sentence against the article. It is not the authors' wording; the abstract and the article are their own account.

What the study did and found

• Design: Cross-sectional mailed survey of physicians
• Who was studied: General surgeons and medical oncologists in Maryland, Washington, D.C., and Virginia who treat patients with gastrointestinal cancer. Surveys were mailed to 2279 physicians, and 116 eligible surveys were analyzed. The article does not give the survey dates.
• Exposure: Not applicable. No asbestos or fiber exposure was studied. The survey asked about access to HIPEC centers, past referrals, opinions on how well the treatment works, and knowledge of its outcomes.
• Main results:
  • Most respondents were general surgeons (79.3%).
  • Most respondents practiced in a community setting (80.9%).
  • An expert in CRS and HIPEC was not easily available to about one third of respondents.
  • Among respondents with a HIPEC expert available, medical oncologists were more likely than general surgeons to report that the expert was more than 30 miles away (52.6% vs. 19.6%, p = 0.006).
  • Among all respondents, 75% would consider referral to a HIPEC center for appendiceal peritoneal metastasis, and 50% would consider it for colon cancer and peritoneal mesothelioma.
  • CRS and HIPEC was considered appropriate for peritoneal metastases from any cancer by 40.7% of general surgeons, compared with 16.7% of medical oncologists (p = 0.03).
  • 72.4% of respondents had referred a patient to a HIPEC specialist in the past, with no difference between general surgeons and medical oncologists.
  • Among respondents who had never referred a patient, the most common reasons were lack of access to a HIPEC specialist (46.9%) and a perceived lack of evidence for the treatment (31.3%).
  • Among respondents who had referred patients, the most common reasons for referral were low-grade appendiceal cancer (81.0%), high-grade appendiceal cancer (58.3%) and colon cancer (48.8%).
  • General surgeons were significantly more likely than medical oncologists to have referred for low-grade appendiceal cancer (86.2% vs. 63.2%, p = 0.02).
  • 65.4% of respondents said a phase III randomized controlled trial showing a survival advantage would influence their future referral decisions.
  • The knowledge questions asked respondents to estimate the five-year overall survival rate after CRS and HIPEC in an experienced center. Two thirds of respondents (66 of 100) underestimated this survival for peritoneal mesothelioma.
  • Five-year overall survival as reported by specialized centers was underestimated by 47.6% of respondents for low-grade mucinous appendiceal neoplasm with pseudomyxoma peritonei, and by 38.8% for colon cancer.
  • Most respondents overestimated 30-day mortality after CRS and HIPEC compared with current results published by experienced centers.
• The authors' conclusion: The authors concluded that referral to HIPEC centers is underused among community physicians. They gave three main reasons: limited access to HIPEC experts, too little direct experience managing peritoneal metastases, and lack of knowledge about when the treatment is used and what its outcomes are.
• Limitations the authors state:
  • The response rate was low (11%).
  • The authors attributed the low response rate to distributing the survey by mail only and to the type of mailing lists used.

Topics

Medical terms in this study, explained in our Lexicon: Cytoreductive Surgery, HIPEC, Chemotherapy, Overall Survival, Metastasis, Colorectal Cancer, Peritoneal Mesothelioma.

Related studies

• Current practice in cytoreductive surgery and HIPEC for metastatic peritoneal disease: Spanish multicentric survey — R. Morales-Soriano, N. Esteve-Pérez, et al. (2018)
• Complete cytoreductive surgery plus HIPEC for peritoneal metastases from unusual cancer sites of origin: results from a worldwide analysis issue of the Peritoneal Surface Oncology Group International (PSOGI) — D. Goéré, G. Passot, et al. (2017)
• Peritoneal metastases of rare carcinomas treated with cytoreductive surgery and HIPEC - A single center case series — A. Brandl, C.B. Zielinski, et al. (2017)
• Current clinical practices of cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy (HIPEC) — M. Acs, M. Babucke, et al. (2024)
• The Role of Ki-67 and Pre-cytoreduction Parameters in Selecting Diffuse Malignant Peritoneal Mesothelioma (DMPM) Patients for Cytoreductive Surgery (CRS) and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — S. Kusamura, P.A. Torres Mesa, et al. (2016)
• Multicystic peritoneal mesothelioma: outcomes and patho-biological features in a multi-institutional series treated by cytoreductive surgery and Hyperthermic Intraperitoneal Chemotherapy (HIPEC) — D. Baratti, M. Vaira, et al. (2010)

Browse more research in Pleura and Peritoneum, or return to medical research.