Impact of Pressurized Intraperitoneal Aerosol Chemotherapy on Quality of Life and Symptoms in Patients with Peritoneal Carcinomatosis: A Retrospective Cohort Study

Abstract

Background. Peritoneal cancer treatment aims to prolong survival, but preserving Quality of Life (QoL) under treatment is also a priority. Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) is a novel minimally invasive repeatable treatment modality. The aim of the present study was to assess QoL in our cohort of PIPAC patients. Methods. Analysis of all consecutive patients included from the start of PIPAC program (January 2015). QoL (0-100: optimal) and symptoms (no symptom: 0-100) were measured prospectively before and after every PIPAC procedure using EORTC QLQ-C30. Results. Forty-two patients (M : F = 8 : 34, median age 66 (59-73) years) had 91 PIPAC procedures in total (1 : 4x, 17 : 3x, 12 : 2x, and 12 : 1x). Before first PIPAC, baseline QoL was measured as median of 66 ± 2.64. Prominent complaints were fatigue (32 ± 4.3) and digestive symptoms as diarrhea (17 ± 3.75), constipation (17 ± 4.13), and nausea (7 ± 2.54). Overall Quality of Life was 64 ± 3.75 after PIPAC#1 (p = 0.57), 61 ± 4.76 after PIPAC#2 (p = 0.89), and 70 ± 6.67 after PIPAC#3 (p = 0.58). Fatigue symptom score was 44 ± 4.86 after PIPAC#1 and 47 ± 6.69 and 34 ± 7.85 after second and third applications, respectively (p = 0.40). Diarrhea (p = 0.31), constipation (p = 0.76), and nausea (p = 0.66) did not change significantly under PIPAC treatment. Conclusion. PIPAC treatment of peritoneal carcinomatosis had no negative impact on patients' overall QoL and its components or on main symptoms. This study was registered online on Research Registry (UIN: 1608).

Figure 1

Treatment algorithm for Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). PIPAC treatment was scheduled as repeated application (3x) at 6-week intervals. Thoracoabdominal computed tomography (CT) was performed 4 weeks prior to PIPAC#1, between PIPAC#2 and PIPAC#3, and after the completion of intraperitoneal treatment to search for extraperitoneal disease. Quality of Life (QoL) was systematically assessed (EORTC QLQ-C30) during every patient encounter: in outpatient consultation, before surgery, and at discharge.

Figure 2

Quality of Life (QoL) under Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) treatment. Overall Quality of Life (QoL: EORTC QLQ-C30 [14]) under PIPAC treatment is displayed (mean ± SEM). (a) No statistically significant difference (p < 0.05) was found when QoL was compared before and after different PIPAC applications (a, b). The dotted lines (b) represent the thresholds for small (SCD) and moderate clinically relevant differences (MCD), respectively [15].

Figure 3

Cognitive, physical, emotional, role, and social functioning under Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). Quality of Life (QoL: EORTC QLQ-C30 [14]) components under PIPAC treatment (mean ± SEM). No significant difference (p < 0.05) was found when QoL was compared before and after different PIPAC applications (ns—not significant).

Figure 4

Quality of Life (QoL) under Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC) in patients with gynecological versus digestive malignancies. Overall Quality of Life (QoL: EORTC QLQ-C30 [14]) is displayed as mean ± SEM. ∗ indicates statistical significance (p < 0.05).

Figure 5

Digestive symptoms under Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). Digestive symptoms were assessed by use of EORTC QLQ-C30 [14] and displayed as difference (Δ before − after). Statistical significance (p < 0.05) is highlighted (bold) and small (SCD) and modest (MCD) clinically relevant differences [15] are illustrated by dashed lines.

Figure 6

Nondigestive symptoms under Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC). Nondigestive symptoms (QoL: EORTC QLQ-C30 [14]) under PIPAC treatment (mean ± SEM). No significant difference (p < 0.05) was found when QoL was compared before and after different PIPAC applications (ns—not significant).

Figure 7

Quality of Life (QoL) change after Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC): 1st application versus repeated procedures. Quality of Life (QoL: EORTC QLQ-C30 [14]) as Δ before − after was compared for PIPAC#1 versus repeated procedures. Statistical significance: p < 0.05. ns—not significant. SCD: small clinically relevant difference, MCD: modest MCD clinically relevant difference [15].

Figure 8

Symptom change after Pressurized Intraperitoneal Aerosol Chemotherapy (PIPAC): 1st application versus repeated procedures. Digestive symptoms were assessed by use of EORTC QLQ-C30 [14] and displayed as difference (Δ before − after). ^∗Statistical significance (p < 0.05). SCD: small clinically relevant difference, MCD: moderate clinically relevant difference [15].

Figure 9

Quality of Life, tumor load, and hospital stay. Overall QoL was plotted against the extent of peritoneal disease (measured by the Peritoneal Cancer Index (PCI) [16]) (a) and length of hospital stay (LoS) (b).

Figure 10

Overall Quality of Life (QoL) in PIPAC patients (Lausanne cohort) as compared with the general population. Overall QoL was compared by use of EORTC QLQ-C30 [14] for the Lausanne PIPAC cohort versus a European cohort of 16,151 healthy citizens (general population). The control group had a slightly better QoL score that was statistically significant but of small clinical relevance (<10%) according to Osoba et al. [15].