Difficult to Treat Cancers with Jeffrey Sutton, M.D.

Some cancers can be difficult to treat through traditional chemotherapy. Metastatic appendix, colon and gynecologic cancers that have spread to the lining of the abdominal cavity can fall into this category. In this episode of Advance with MUSC Health, Jeffery Sutton, M.D., talks about a surgical treatment that involves using heated chemotherapy inside the abdominal cavity to kill cancer cells. The procedure is called hyperthermic intraperitoneal chemotherapy or HIPEC and offers many patients incredible results.

“There are patients who are presenting with stage four disease still alive five, eight, 10 years later (after this procedure) … Unfortunately, most patients, once they’re stage four, the chance of cure is rather low. And so, oftentimes, what my goal in the surgery and offering the patients is to prolong both the quality and the quantity of life and hopefully allow patients to see their grandchild’s graduation or be around for that next anniversary.”

- Jeffrey Sutton, M.D.

Topics covered in this show

• Sutton says one of the reasons these types of tumors are difficult to diagnose and treat early on is the vagueness of the symptoms that patients can present with. He says vague nausea and cramping is often chalked up to constipation or irritable bowel. A lot of times he says patients don't present with many symptoms at all, until the disease has spread beyond where it started.
• The HIPEC procedure is used when appendix, colon and gynecologic cancers tumor cells land on the lining of the abdominal cavity, called the peritoneum, and start to grow. Sutton tries to resect the tumor deposits during the HIPEC procedure.
• HIPEC stands for heated, intraperitoneal chemotherapy, a two-part procedure. The first part involves removing all the cancer that surgeons can see on the organs. The second part uses a heated, intraperitoneal chemotherapy to kill all the microscopic, tiny cells that may persist.
• HIPEC is not a surgery that is offered in a lot of places, Sutton says. It is a specialized procedure that requires a lot of training and is recommended to be performed at higher volume centers, such as MUSC Health.
• Sutton’s goal is to make HIPEC a standard surgery at MUSC and have it be one of the many options to offer patients with metastatic cancer.

Read the show transcript below

Erin Spain [00:00:04] Welcome to Advance with MUSC health, I'm your host, Erin Spain. This shows the mission is to help you find ways to preserve and optimize your health and get the care you need to live well. Some cancers can be difficult to treat with traditional chemotherapy. Appendix, colon and gynecologic cancers that have spread to the lining of the abdominal cavity can fall into this category. MUSC Health is one of the few locations in South Carolina to offer such patients a surgical treatment that involves using heated chemotherapy inside the abdominal cavity to kill cancer cells. This procedure is called HIPEC. Here, to discuss the procedure and the incredible results it offers many patients is Dr. Jeffrey Sutton. He is a surgical oncologist at MUSC Health and the Hollings Cancer Center. Welcome to the show, Dr. Sutton.

Jeffery Sutton, M.D. [00:00:57] Thanks so much, Erin. Great to be here.

Erin Spain [00:00:58] Tell me a little bit about your path to becoming a surgical oncologist.

Jeffery Sutton, M.D. [00:01:02] Some people say they have that aha moment where they say “This is the reason I want to do surgery.” “This is the reason I want to go into medicine.” You know, thinking back, I've always been interested in surgery. I love using my hands. I love the instant gratification of performing a procedure and getting instant results. So, I don't really have that aha moment, but just something I've always been interested in. It wasn't until my third year of medical school in which we rotate in a different surgical services that I became interested in surgical oncology as a specialty. What I loved was the variety of cases. The simple melanoma decisions are the very much larger exceptions lasting all day long and working with these patients in a very vulnerable time in their lives and just achieving good outcomes and giving them hope. So, I like that aspect of surgical oncology is removing cancer and getting those instant gratification results.

Erin Spain [00:01:51] As you mentioned, a lot of these people, it is a very difficult time in their lives. Most of the patients you see with metastatic appendix colon or gynecologic cancers when they discover their disease, what sort of symptoms are they experiencing?

Jeffery Sutton, M.D. [00:02:04] Excellent question. There's a large variety of symptoms that these patients can experience. One of the reasons is typical tumors are difficult to treat, sometimes, is the vagueness of the symptoms that these patients can present with. Oftentimes, they'll just have a vague nausea. Maybe some more pain, some cramping. Chalk it up to constipation or irritable bowel. A lot of times patients don't present with many symptoms at all, unfortunately, until the disease has spread beyond where it started. Of course, you do get a lot of typical symptoms associated with these tumors, such as appendicitis. If you have a tumor in the appendix, that's blocking it. You can get the typical abdominal pain blood in your stool, symptoms that accompany colorectal cancer and similar to the GI and organs where you can just have sort of a vague lower abdominal or pelvic cramping that makes these tumors difficult to diagnose upfront.

Erin Spain [00:02:54] And these tumors, they're different sometimes than other cancer tumors. These tumors of the appendix colon gynecologic cancers tell me about that.

Jeffery Sutton, M.D. [00:03:02] Depending where the organs live in the body can also determine where they sort of metastasized. You or they shed their tumor cells to the appendix and the ovaries as prime examples. They live down in the pelvis and they're sort of free floating, if you will. And so, when they have tumors within them that grow large enough to grow through the the wall of the organ, they can shed cells into the lining of the space around it. And so, it tends to allow for these tumors to spread into what's called the peritoneal cavity or the space in which most of the organs live in the body. That's different from a pancreas cancer, for example, which oftentimes will spread through the bloodstream or the lymphatic channels to the liver. The pancreas can also shed cells into the cavity surrounding it, but typically organs like the appendix, the ovaries, the stomach. They can sort of shed cells, and those tumor cells can sort of land on the nearby organs or lining of the abdominal cavity called the peritoneum and start to grow. And those become the tumor deposits that we hopefully help to resect during the HIPEC procedure.

Erin Spain [00:04:06] So tell me about HIPEC. How does it work and how do you use this specialized surgery on patients?

Jeffery Sutton, M.D. [00:04:13] HIPEC itself is an acronym that stands for heated, intraperitoneal chemotherapy. The surgery itself is actually a two-part procedure. The first part involves something called site or reduction, where we go in and remove all the cancer that that we can see with our eyes remove all the macroscopic cells. Sometimes that involves taking out the appendix and the right side of the colon. Somehow, that involves taking out things like the abdomen or different areas of small intestine. Sometimes it involves taking out ovaries, fallopian tubes, uterus. In addition, sometimes it involves removing the lining of the peritoneum, which is, I think, of like the wallpaper of the the abdominal cavity. There's tumor nodules or deposits along that. We typically like to remove that. So, we remove all the macroscopic disease that we can see. That step one step, two is the HIPEC portion. We use a heated, intraperitoneal chemotherapy to kill all the microscopic, tiny cells that may persist. It does us no good to go in and leave cancer behind, so we take out as much as we can see with our eyes and feel with our hands and then treat the microscopic disease afterwards with the hot chemo.

Erin Spain [00:05:20] And how long is the chemo in there sort of washing that cavity in a way? Right? Correct.

Jeffery Sutton, M.D. [00:05:25] Yes. So, the surgery itself can be an all-day affair. The majority of the time is actually spent during the side, a reduction of the surgical part. Sometimes we have a good idea based on preoperative imaging, how much disease exists in the abdomen. But sometimes we get inside, and tumors can be tricky. They can be much smaller than we can typically see on a cat scan. And so it may be that there's lots of tiny nodules spread throughout, which would be underestimated by CT scan findings. So, once we get in there and remove all the tumor, we then treat the patients with the heated chemotherapy for about 90 minutes. After that, we we do sort of clean up. We do it anastomosis, we saw the bowel or stable the ball back together and then close the abdomen. So again, sometimes that can be a four-hour procedure. In all total, sometimes I've done HIPECs that lasted up to 14-15 hours sometimes.

Erin Spain [00:06:16] And this is a very specialized surgery. So, tell me about your path to giving this surgery.

Jeffery Sutton, M.D. [00:06:21] So I was fortunate enough as part of both my residency training and my fellowship training to have a lot of experience in treating these patients. I was fortunate enough to train at the University of Pittsburgh Medical Center for my Surgical Oncology Fellowship, in which we did multiple HIPECs per week. So,it's not a surgery that is offered in a lot of places like typical gallbladder or hernia surgery. This is a much more specialized procedure that requires a lot of training and is recommended to be performed at higher volume centers. So, I'm fortunate of based upon my my training experience and the mentors I've worked with to be taught this technique and to be able to utilize it to help patients in South Carolina and beyond

Erin Spain [00:07:04] This sort of surgery, the outcomes can really be impactful for patients. It can really improve their chances of living a longer, healthier life, with many of them have metastatic cancer. Tell me about how successful this surgery can be.

Jeffery Sutton, M.D. [00:07:17] You're right. We are pushing the envelope in terms of who we are considering surgical candidates. You know, it used to be that anyone gets diagnosed with stage four disease. They're ultimately considered non operative, and they go down the chemotherapy or radiation route alone. We are really advancing the field in terms of who we are considering operative candidates and who we're offering surgery to, especially in this setting of metastatic or stage for disease in terms of success rates. A lot of it depends on several factors. Number one is what organ are we actually treating? The appendix, the ovaries, the stomach, the colon and rectum, they can all present with similar intra-abdominal metastases. Not all tumors act the same, though there are low grade ones that are slower growing. There are high grade ones that are the more aggressive and faster growing. Even within the appendix, you can have lower grade or slower growing tumors, which can be treated well and even offer an opportunity for cure or as some of the tumors in the appendix, or most of the tumors in the appendix where we're trying to sort of extend life and minimize symptoms. So, a lot of it depends on the patient's particular organ involvement, the the grade or the aggressiveness of the tumor itself, how much disease exists. That being said, though, there are patients who are presenting with stage four disease who are still alive, you know, five, eight, 10 years later. So, there are certainly a lot of discussion that goes into choosing which patients are optimal candidates for the surgery. We always present these patients that are a multidisciplinary tumor board, so we get buy in from surgeons, from radiologists, from medical oncologist and radiation oncologist, from GI doctors. And so, we all sort of view and treat cancer through different lenses, and it's helpful to have those different viewpoints to determine which patients may benefit most from the treatment. Unfortunately, most patients, once they’re stage four the chance of cure is, is rather low. And so oftentimes, what my goal in the surgery and offering the patients is to prolong both the quality and the quantity of life and hopefully allow patients to see their grandchild graduation or be around for that next anniversary.

Erin Spain [00:09:29] So what is the window of time that's most optimal for this surgery? I know it might depend patient to patient, but when would you say is the best time to have it for the best outcome?

Jeffery Sutton, M.D. [00:09:39] There are really two sets of patients who get diagnosed with metastatic disease. There are those who present with stage four disease upfront, so no knowledge of any cancer. They may have some symptoms, or they may get a colonoscopy, which finds a colon cancer and your workup eventually diagnosis a metastatic lesion in the liver or around the abdomen. There are also patients who had a previously resected cancer and have gotten their chemo and may maybe down the road, maybe six months a year, two years, four years present. Now, all of a sudden, on surveillance hearing, they have a new spot, or they have several spots, and they have new symptoms, which warrants that workup. And so, a lot of it depends on where in the treatment course the patient is typically of patients present with what we call synchronous lesions, meaning say they have a cancer in the appendix that they didn't know about. And all of a sudden, it's already spread. Those patients will tend to get chemotherapy upfront through the veins. The typical chemotherapy we think of and then is determined afterwards whether they are good candidates for the HIPEC procedure or not. And that typically ranges from about three to six months of of chemotherapy. Now there are also patients who had a previously resected cancer, and maybe they've already gotten systemic or IV chemotherapy who present a year or two later with disease. Now, if there's relatively little disease and tumor burden at that point, then those patients may be candidates for HIPEC upfront without needing additional IV chemotherapy right away. So again, there's a lot of nuances to this, and fortunately, my training has allowed me to appreciate the nuances of this and know which patients may benefit. But a lot of it is based on where an individual patient is in the the treatment course and where their tumor started and how long it's been since it was diagnosed.

Erin Spain [00:11:26] Besides the chemotherapy being warmed and heated, how is it different than the traditional chemotherapy that goes in the vein? This chemotherapy, for example, doesn't cross into the bloodstream? Why is that important in terms of the heated aspect.

Jeffery Sutton, M.D. [00:11:39] We know from studies done in the 1970s in animal models that this chemotherapy, when heated, tends to penetrate a little bit deeper. And so again, when you think about what HIPEC is treating, HIPEC is not treating the tumors inside the liver or inside the lungs are inside organs. It's treating the tumors that are sitting around or on top of organs. And so, while we don't need the chemotherapy to penetrate deep, we do need to penetrate a couple of millimeters in order to make sure that all the tumor nodules that are lining these organs and line the perineal cavity are getting treated. So, the hypothermic of the heated aspect of this chemotherapy, we know, allow that to penetrate just a little bit deeper to maybe get another millimeter or two of disease and treat those residual disease nodules. Now the beauty of this chemotherapy is that, as you mentioned, it doesn't cross into the bloodstream. A lot of these side effects are symptoms people have from traditional chemotherapy is based on the intolerance of the toxicity of that chemotherapy. As it floats around the bloodstream, it interacts with the heart, it interacts with the liver, it interacts with the lungs, with the nerves. And so, when medical oncologist calculates how much chemotherapy patients should get, it's based on body size, body weight tolerance, how much chemotherapy they've gotten in the past because all those effects can result in significant toxicity. You know, if you think about, it'd be great to give a patient a very concentrated chemotherapy. But if they can't tolerate it and it's very toxic and the side effects are prohibitive, then it does no good to treat them with it. So medical oncologists are tasked with finding that delicate balance of finding the perfect dose that's strong enough, but not too strong. Sort of. The Goldilocks dose where that differs for the HIPEC procedure is that maybe two or three percent of this chemotherapy drug is getting absorbed, meaning we can use a significant concentration, much higher concentration of these chemotherapy agents in the cavity itself and have it be much more effective at killing cancer cells than we can with the traditional chemotherapies. If we use the typical HIPEC chemotherapy at that same dose in the bloodstream, patients would be extremely sick, and no one would would even want to undergo those systemic chemotherapy treatments. So, in short, we're able to use very efficacious drugs and chemotherapeutic agents at very high concentrations that wouldn't otherwise be tolerated through the veins.

Erin Spain [00:14:04] Tell me about recovery, then. For people who go through this procedure, what is it like?

Jeffery Sutton, M.D. [00:14:09] So typically patients are in the hospital for about a week or two. Like any major surgery, complications can happen. So, there are things that we're very wary about and watch out for. But the recovery is not much different from a typical sort of large surgery. Patients are in the hospital for a week or two. They go home, usually eating. Moving their bowels sometimes may go to rehab depending on how long they're in the hospital for. And patients may feel sort of worn down fatigued, maybe some abdominal cramping for a couple of weeks or months after the surgery. But typically, the recovery is very similar to and based upon whatever they had undergone from a sudden reduction standpoint. So, patients have multiple areas of the bowel resected and multiple procedures done during this sort of first half or the CO2 reduction portion of the surgery, then they may have a longer recovery if there's relatively little disease burden and we get in and we remove some nodules or there even patients who, as I mentioned, have had their major surgery in the past. We're just going into sort of clean up some nodules and remove small tumor burden, and we don't actually remove any bowel and those patients will have a very fast recovery.

Erin Spain [00:15:16] Tell me about HIPEC and how it's used at MUSC Health, how many surgical oncologists like yourself do the procedure? How many are taking place at home?

Jeffery Sutton, M.D. [00:15:24] MUSC health being a large tertiary academic medical center and the only one in Charleston and and really the only National Cancer Institute Designated Cancer Center in South Carolina. There's a lot of opportunity to offer patients cutting-edge, high-quality cancer care, which is one of the reasons I came here and was recruited to bring HIPEC to MUSC Health is currently being performed here at MUSC, but my goal is to increase the volume of patients and increase our recruitment from the surrounding areas and make HIPEC a standard surgery that we become known for here at at MUSC. And just one of the many options to offer patients with metastatic cancer. I also have an interest in teaching residents and medical students. So, of course, MUSC boasts a very large general surgery residency program and excellent medical school, and I look forward to teaching them, you know, cancer care and taking care of cancer patients.

Erin Spain [00:16:18] If someone's listening to this podcast right now, maybe they're trying to find out more about high impact. Maybe someone in their family is considering it. Why should they come to MUSC Health for a consultation and learn more?

Jeffery Sutton, M.D. [00:16:30] One of the challenges I've encountered in managing cancer patients is that there can be a lot of incorrect information that people read about online or hear about through friends. Cancer comes a lot of questions. It's a very complex and confusing diagnosis, especially when you're dealing with metastatic stage for disease. My goal when I meet with patients and interact with them for the first time is to answer as many questions about the disease process as I can. That can be about the cancer itself. It can't be about the treatment, the potential complications, the benefit, the longevity. There's a lot of questions that people come with, and not everything you read online is going to be accurate. So, my goal is to make sure that patients have a better understanding of their diagnosis, a better understanding of their treatment options and also entertain those options, be it surgical or systemic chemotherapy, radiation or a combination of the three.

Erin Spain [00:17:21] What do you do to optimize your health and live well?

Jeffery Sutton, M.D. [00:17:24] In addition to trying to eat right and exercise? I do love to golf, and as a melanoma surgeon, I'm very religious about applying and reapplying sunscreen on the golf course. I am fairly fair skinned, so I'm prone to burning, and I know that many years of of sunburns down the road could increase my risk of melanoma. So, I like to tell all patients to enjoy the outdoors, to get your vitamin D, but also to apply sunscreen and avoid the sun when possible.

Erin Spain [00:17:56] For more information on this podcast, check out advance.muschealth.org