Monday Night Cancer Club is a Daily Kos group focused on dealing with cancer, primarily for cancer survivors and caregivers, though clinicians, researchers, and others with a special interest are also welcome. Volunteer diarists post Monday evenings between 7-8 PM ET on topics related to living with cancer, which is very broadly defined to include physical, spiritual, emotional and cognitive aspects. Mindful of the controversies endemic to cancer prevention and treatment, we ask that both diarists and commenters keep an open mind regarding strategies for surviving cancer, whether based in traditional, Eastern, Western, allopathic or other medical practices. This is a club no one wants to join, in truth, and compassion will help us make it through the challenge together.My husband was diagnosed with colon cancer in April, 2006. It was metastatic, mucinous adenocarcinoma that extended through the wall of his colon into the omentum (a layer of fat that drapes over the intestines) and had spread to two of his lymph nodes--stage IIIb. Once we got over the shock of the diagnosis, we tried not to think too much about stages and statistics, but focus on the positives--the tumor was removed with clear margins, the cancer was found in only 2 of 14 lymph nodes, and there was no metastasis to the liver or lungs.
He had a temporary colostomy, six months of chemotherapy and then, in November, surgery to resect his colon. The pathology report showed no malignancy and the PET/CT scan came back with no evidence of disease, so it all seemed like good news. But my husband was still at high risk for recurrence because of the omental metastasis. Also, mucinous adenocarcinoma is a carcinoma that has a lot of mucus, allowing cancer cells to spread faster, making them more aggressive. The oncologist recommended another set of chemotherapy as, in his words, "insurance" against the possibility of recurrence. So that's what we did, in 2007, with annual colonoscopies and CT scans at the beginning of each new year as follow up.
Other than those annual tests and the physical scars on his abdomen as reminders of what we'd been through, there were no particular feelings of dread in either of us. As has been touched on previously in the Monday Night Cancer Club, we were floating in a sea of hope and positive feelings. Even the inconclusive report from the January, 2010 CT scan didn't have us thinking the cancer had returned, especially because his colonoscopy results were negative. The CT scan showed slight radiotracer uptake in two spots--near the right ureter and close to the bladder. Surgery was scheduled in early March--almost 4 years after his first surgery and cancer diagnosis--to remove and biopsy a small growth on the ureter and put in a stent. Our biggest concern going into the surgery was that the right kidney would have to be removed because of the swelling caused by the back up of urine.
Afterwards, the surgeon told us to start chemotherapy without delay. Two tumors had been found growing from the outer wall of the colon into the abdomen. The larger one, about the size of an orange, was pressing against the ureter, causing damage to the kidney beyond repair. The smaller one, lower down the colon, was pressing against the bladder. There was a small tumor in the abdominal wall near the site of his temporary colostomy and other smaller spots scattered through the omentum. Except for a tumor in the small intestine that was removed because it was close to causing obstruction, the rest were left to be treated with chemotherapy.
Within four weeks chemotherapy treatments were started. This time, along with the 5-fluorouracil my husband received Avastin. Oxaliplatin was added to the mix but discontinued because of neuropathy in the hands and feet. The oncologist said my husband would have to be on chemotherapy for the rest of his life, or for as long as he could tolerate it. CT scans were scheduled at three month intervals, and although the tumors responded early on by shrinking by about thirty percent, progress then seemed to hit a plateau.
Dear readers, are you still with me? Not bored to death, I hope. Because it took all of this to get us to consider CT and HIPEC. CT is cytoreductive surgery or debulking, where a surgical oncologist removes as much of the cancerous tumors as possible. This is then followed by hyperthermic interperitoneal chemotherapy, a heated chemotherapy solution that is circulated through the abdominal cavity while the patient is still in under anesthesia.
HIPEC treatment is used for cancers that have spread in the abdomen, most commonly colon cancer, ovarian cancer and appendiceal cancer. As well as the direct contact of the chemotherapy drugs with the cancer cells, heating the drugs increases their effectiveness. I found this to be one of the better links showing the HIPEC procedure. With a series of catheters and a pump, the heated solution is circulated through the peritoneal cavity for up to two hours. Some patients continue chemotherapy intravenously, others may not need the treatment.
I'm also going to include another link, for a NY Times article: Hot Chemotherapy Bath: Patients See Hope, Critics Hold Doubts, because there is some good information for people considering the procedure. This was the first mention, in my search for information about HIPEC, that the procedure was considered to be controversial.
For us, the decision to go through with CT/HIPEC was made without too much difficulty. Even after the surgical oncologist informed us that it was going to be much worse than any of the other surgical procedures my husband had undergone, we also knew that the odds for survival from recurrent colon cancer were very, very low.
We were warned that the cytoreduction procedure would be very lengthy, anywhere from 6 to 12 hours. The heated chemotherapy, in direct contact with the tissues of the abdomen and all the organs it contains, would cause a great deal of swelling and discomfort, besides the normal post-surgical swelling.
The biggest risk of complication would be perforation of the bowel in the weeks after the surgery, a side effect of Avastin. (This side effect is present even without CT/HIPEC, but the risks are greater with the direct exposure of the colon to the chemotherapy drugs.) The very thing that makes Avastin effective against some tumors makes the cells it targets more susceptible to breaking down and leaving a hole in the colon wall. It works by blocking VEGF, a protein that helps in the formation of blood vessels that provide tumors with the oxygen and nutrients the need to grow.
Unfortunately, my husband's colon did perforate and an expected ten to fourteen day hospitalization lasted six weeks. Recovery was slow, but he was just so happy to have a break from intravenous chemotherapy treatments! While his CT scan results have been tentatively good, there are a few spots being watched carefully. We no longer have the luxury of expecting a complete cure as we had hoped for at the time of his first diagnosis.