Rutgers Cancer Institute of New Jersey
195 Little Albany Street
New Brunswick, NJ 08903-2681
With a thriving family plumbing business, her only child in high school and her family settled in their dream home, Lisa Schepisi already looked at life as a gift. What she didn’t know at that time in 2004 was that for the next 12 years, each day would become a precious treasure. Diagnosed with appendix cancer that year at the age of 40, she began an unexpected journey of multiple recurrences and treatments including a major, invasive surgery only offered at a handful of specialty centers across the country. Drawing on personal strength and humor, her loving husband, daughter, close family and friends, and a care team involving her community oncologist and specialists at Rutgers Cancer Institute of New Jersey, she had the support she needed to undergo that unique procedure not once – but twice.
After learning the extreme abdominal pain she was having was a result of appendiceal carcinoma, her appendix and surrounding tissue were removed and she began chemotherapy under the care of local oncologist James Salwitz, MD. A routine CT scan during a follow-up visit in 2009 showed a pelvic mass. She was referred to Rutgers Cancer Institute, where she had a full hysterectomy, temporary colostomy and partial colon removal and was set on another course of chemotherapy. While she resumed normal activity like going back to work as a weight loss coach and helping with the family business, she suffered the loss of her mother shortly after. “Throughout this whole experience, people have said that I’m so strong. It’s really a type of survival instinct I have. But given everything that was happening, 2009 was a difficult time for me,” shares Schepisi, who had to draw upon that survival instinct again and again over the next few years.
In 2010, Schepisi was met with another suspect CT scan, which revealed masses consistent with the presence of cancer in a thin layer of tissue in the abdominal cavity known as the peritoneal lining. Returning to Rutgers Cancer Institute, surgeons deemed Schepisi would benefit from a unique combination procedure known as cytoreductive surgery (CRS) and hyperthermic intraperitoneal chemotherapy – or HIPEC – but it wasn’t being offered at the facility at that time. In fact, the procedure was only available at a few northeast locations. After learning someone in her family circle had undergone this specialized surgery at a Baltimore hospital, that is where she decided to go.
"I wasn’t going to let my cancer be in control of me. I was going to be in control of it," recalls Lisa Schepisi in deciding on a second HIPEC cancer treatment.
Around for about two decades, CRS – HIPEC treats cancers of the abdominal cavity and abdominal lining including appendix, colon, and stomach cancers, as well as some cases of ovarian cancer and mesothelioma. The procedure, which can take anywhere from six to 15 hours, involves removing all or most of the tumor and even affected organs if they are not critically needed. Chemotherapy heated to 107 degrees Fahrenheit is then administered directly into the abdominal cavity, bathing the area for an average of 90 minutes before it is drained and the area stitched closed.
While the surgery itself is very involved, so is post-surgery recovery, with an average hospital stay of seven to 14 days. Schepisi awoke to multiple tubes inserted in her body for breathing, nutrition, draining of fluids, medication and waste excretion. She stayed in the hospital for 10 days, then another 10 days in a nearby hotel so she could be close to the Baltimore care team for immediate follow-up visits.
The many weeks that Schepisi and her husband Ken spent in Baltimore away from their business took its toll in many ways including emotionally and physically. After coming home to New Jersey, Schepisi was soon hospitalized for dehydration and couldn’t eat or drink for nearly a week but was eventually released. The events had a financial impact on the family as well. For years their plumbing business was successful, but around the time of the surgery, the economy started to decline. They sold their dream house in Monroe Township and downsized to another home in the same town. “Every day Ken would ask me how I felt, and I would simply go through the motions and just tell him I was ‘okay.’ But one day after about three months, I really did feel ‘okay’ and started to rebuild our life,” she says. This included workouts at the gym and going out with friends. Schepisi also took stock in everyday activities such as curling up on the couch with Ken and their dog Juicy, as well as spending time in her recently renovated kitchen baking – a pastime she enjoyed with her late grandmother.
Things remained calm for the next few years and follow-up visits remained status quo until January 2016 when Schepisi experienced the uncomfortable sensation of food getting stuck in the top of her stomach. After calling her local oncologist, she was instructed to go to the emergency room where a CT scan was taken. It showed a blockage, but there was uncertainty as to whether a shadow that presented was the result of surgical scar tissue or was an indication of cancer. Her doctor immediately referred her to Timothy Kennedy, MD, a surgical oncologist in the Gastrointestinal/Hepatobiliary Oncology Program at Rutgers Cancer Institute. Dr. Kennedy came to see Schepisi in the ER and informed her that what they were seeing was indeed cancer. He also told her she needed a second HIPEC surgery – a procedure Kennedy was more than familiar with, having performed about 70 of the operations over the past five years. But he shared that she didn’t need to have the procedure right away, since the new malignancy appeared to be slow growing.
Schepisi didn’t hesitate. “I wasn’t going to let my cancer be in control of me. I was going to be in control of it,” she recalls. It was a matter of whether going back to Baltimore since she was already familiar with the procedure and team there or working with a new doctor and having the benefit of being close to home. The Schepisis decided that proximity was important, plus, having been at Rutgers Cancer Institute in previous years, there was also a level of comfort and trust with the expertise there. Schepisi’s blockage resolved and she immediately arranged to have HIPEC later that month with Kennedy at Robert Wood Johnson University Hospital, the flagship hospital of Rutgers Cancer Institute.
A second HIPEC surgery is not unusual, notes Kennedy, who quickly points out that the procedure – whether a first time or second time – is not for everyone. “Looking at the biology of the disease is most important. If it’s a slow growing cancer like low-grade appendiceal, there is more benefit in removing the disease and treating with HIPEC, because it can take many years for the cancer to grow back. For more aggressive cancers like colorectal and gastric, we would treat with systemic chemotherapy first to assess response before considering patients for aggressive surgery. Those with slow growing cancers and disease that is responding to chemotherapy are good candidates for the procedure. Patients who are also young and healthy like Lisa tend to have better outcomes,” notes the doctor, who is also an associate professor of surgery at Rutgers Robert Wood Johnson Medical School. “The risks outweigh the benefits in some cases, but it really needs to be taken on a case by case basis. There is a survival benefit for many patients,” he says. Kennedy adds that unfortunately, study on CRS and HIPEC has been extremely limited, but points out “those who have the procedure at a specialty center tend to have better outcomes,” adding that about 100 facilities across the country currently perform HIPEC, with about 20 to 30 of those locations being some type of specialty center. With the arrival of the program’s newest surgical oncologist Miral Grandhi, MD, an assistant professor of surgery at Rutgers Robert Wood Johnson Medical School, Kennedy is looking to build on HIPEC offerings at Rutgers Cancer Institute and develop a HIPEC center of excellence for central New Jersey.
"Those with slow growing cancers and disease that is responding to chemotherapy are good candidates for HIPEC. Patients who are also young and healthy like Lisa tend to have better outcomes," notes Lisa Schepisi’s surgeon Tim Kennedy, MD.
While pre-surgical assessment through a tiny incision can be utilized to determine which patients will benefit from CRS and HIPEC, Kennedy says it’s not common to do CRS and HIPEC through a minimally invasive approach unless the disease is very limited. Mostly, patients have extensive disease throughout the peritoneal area. With that, an incision is made at the top of the abdomen down to the pelvic region. The aim, says the surgeon, is to achieve complete cytoreduction – either no disease or having all tumors remaining under 2.5 millimeters. The debulking – or surgical procedure to remove disease – can take four to 12 hours on its own. Some of this time can be spent just getting through scar tissue, but much of it involves peritonectomy procedures and intestinal re-connections following the removal of any involved organs. Kennedy approaches each case by dividing up the needed surgical removals into multiple, smaller operations. One thing he believes is unique to his technique is that he tries to focus on disease removal and spares affected organ as much as he can. “It may be be easier to remove an entire organ, but that could lead to a poor quality of life for the patient or risk of complications,” he shares. Kennedy also tries to limit the number of bowel connections to limit complications and risk of infection.
Following the actual surgical debulking, catheters are placed in the abdomen and the abdomen is stitched closed. Subsequently, saline is administered into the abdominal cavity and heated to 107 degrees. The chemotherapeutic agent is then added. Mitomycin C is given in most HIPEC procedures, as this particular drug doesn’t absorb in the body as much as other chemotherapies that might cause toxicity to organs at high doses. The heated solution is then manually agitated through the cavity using a pump that is monitored by specially trained circulating nurses. Kennedy notes the heat is important, as it’s been shown that cancer cells are more sensitive to heat, thus more of them are destroyed. He adds HIPEC requires a comprehensive team, from nurses and scrub techs, to pharmacists, uro-oncologists, gynecologic oncologists, and plastic/reconstructive surgeons. Perfusion specialists who handle the chemotherapy pumps are key, as well as a nutritionist to help patients with dietary intravenous needs since it takes an average seven to 14 days for normal digestive function to resume.
Schepisi was ready for the second HIPEC – and even knew the risk of the doctor going in and realizing he may not be able to proceed. A seriousness came over the surgical team as they prepared her in the operating room. “I just looked at them and told them ‘this isn’t my first rodeo.’ I think I may have scared them, but it’s just my brand of humor,” she muses. Her “humor helps” mantra has been evident through many aspects of her journey. For instance, Schepisi had her hair styled by daughter Nicole – a hairdresser – during one of her visits when she needed a blood transfusion. This is also the woman who misinterpreted the immediate need for a stool sample and ended up bringing one in her designer handbag to be evaluated. After jokingly calling out Kennedy on that misunderstanding, patient and doctor shared a hearty laugh.
Following the procedure, it took Schepisi about a month for her to feel “normal” again as compared to three months the first time. “I was back at the gym doing spin classes and eating and drinking again – all in a short amount of time,” she happily recalls. Schepisi attributes a quicker recovery to having an epidural for pain management after the second surgery versus more powerful post-operative medications given after the first procedure. Kennedy was more than pleased. “There’s no formal study on this, but I believe a positive attitude and outlook are important and are associated with an easier recovery,” says the surgeon.
Schepisi was offered systemic chemotherapy after both procedures – anti-cancer medication designed to circulate throughout the entire body instead of just a targeted area. She decided against it both times. “For low-grade appendiceal cancer, it’s less known if systemic chemotherapy provides a survival benefit. We do know this follow-up treatment provides some benefit and improves survival for those with more aggressive cancers like colorectal and gastric. It’s really a quality of life issue,” notes Kennedy. Schepisi is on a schedule to follow up with Kennedy and team every few months, and she’s not on any medication.
Married 31 years in October 2016, Schepisi and her husband “put a lot of things on hold” while she endured each leg of her cancer journey, but she knows life is good. “My quality of life is great. I really can’t complain,” Schepisi notes. She’s been keeping up with the gym and going on vacation. The couple even took in a recent Bruce Springsteen concert complete with limo and dinner – overall, just taking things “one day at a time.” ■