What’s the Difference Between HIPEC and PIPAC?
PIPAC and HIPEC are chemotherapy treatments that doctors use to treat peritoneal mesothelioma, a rare cancer that starts in the lining of the abdomen (peritoneum). Both approaches administer chemotherapy drugs directly to the cancer site, but one requires major surgery while the other does not.
- HIPEC, which stands for hyperthermic intraperitoneal chemotherapy, is a heated liquid chemotherapy delivered directly into the abdominal cavity during cytoreductive surgery.
- PIPAC, which is short for pressurized intraperitoneal aerosol chemotherapy, delivers chemotherapy as a fine pressurized mist using small surgical openings and a camera.
HIPEC is used with curative intent, meaning the goal is to extend life expectancy and control the cancer for as long as possible. PIPAC is typically used with palliative intent, meaning the focus is on slowing the cancer and easing symptoms.
Doctors choose between HIPEC and PIPAC based on several factors, including how far the cancer has spread, whether tumors can be safely removed, and the patient’s overall health.
“HIPEC is essentially used for curative purposes and PIPAC for palliative intent…HIPEC may be favored due to its one-time, intense approach in curative settings, but PIPAC may be appropriate for individuals who are unable to undergo major surgery.”
– Dr. Praveen Kammar, surgical oncologist
Download our Free Peritoneal Mesothelioma Guide to better understand your treatment options and prepare for conversations with your doctor.
Side-by-Side Comparison of HIPEC vs. PIPAC
Even though PIPAC and HIPEC both deliver chemotherapy directly into the abdomen, they vary in how invasive they are, who they are best suited for, and what recovery looks like.
| Feature | HIPEC | PIPAC |
|---|---|---|
| What it is | Heated liquid chemotherapy circulated in the abdominal cavity | Chemotherapy delivered as a pressurized aerosol (fine mist) |
| Who it’s usually for | Patients whose visible tumors can be safely removed | Patients whose cancer cannot be safely removed or is widespread |
| How it’s given | During major surgery, after tumors are removed | Through small incisions using a camera (laparoscopy) |
| Surgery required | Yes, major abdominal surgery | Yes, minimally invasive surgery |
| Tumor removal | Yes | No |
| Recovery time | Longer recovery, often weeks | Shorter recovery, usually days |
| Can it be repeated? | Rarely, because it is a major procedure | Yes, it is designed for repeat treatments |
| Side effects | Higher risk due to extensive surgery and chemotherapy | Generally fewer side effects for most patients |
| Main goal | Long-term disease control and improved survival | Disease stabilization and symptom relief |
| Common drugs used | Cisplatin, doxorubicin, mitomycin, or oxaliplatin | Cisplatin and doxorubicin (most commonly) |
Looking at these differences together can help clarify why your care team may recommend PIPAC instead of HIPEC, or vice versa. The right choice depends on the details of the cancer and your overall health.
How HIPEC and PIPAC Work to Treat Peritoneal Mesothelioma
Both mesothelioma treatments follow a clear set of steps, from how chemotherapy is delivered to what recovery may involve. Knowing how these procedures work can help patients and caregivers feel more prepared for discussions with doctors.
HIPEC Process
HIPEC is part of a larger procedure called cytoreductive surgery with HIPEC. Doctors usually recommend it when they believe most of the mesothelioma cancer can be safely removed.
Here’s how the HIPEC procedure works:
- Tumor removal surgery: The surgeon removes visible cancer from the abdomen, including tumors and cancerous areas of the abdominal lining.
- Heated chemotherapy treatment: After surgery, heated liquid chemotherapy is circulated throughout the abdomen for about 60 to 90 minutes. The warmth helps the chemotherapy reach and destroy cancer cells that are too small to see.
- Completion of surgery: The chemotherapy is drained, and the surgeon closes the incisions to finish the procedure.
Recovery from HIPEC usually takes several weeks because it involves extensive surgery. When it’s a good fit, however, it can help manage peritoneal mesothelioma and keep it from growing or spreading.
PIPAC Process
PIPAC is a minimally invasive treatment designed for patients who may not be candidates for cytoreduction with HIPEC.
Here is how the PIPAC procedure works:
- Small surgical openings: The surgeon makes 2 or 3 small incisions to place a camera and tools into the abdomen.
- Chemotherapy mist delivery: Chemotherapy is released as a fine mist, allowing it to spread across the abdominal lining.
- Closed-abdomen treatment: The abdomen remains closed for about 30 minutes so the medication can fully coat the organs and surfaces.
- Repeat treatments: PIPAC is usually repeated every 6 to 8 weeks if the patient tolerates it well.
Because PIPAC doesn’t require large incisions or tumor removal, recovery is usually faster, and patients can usually go home within a day or two.
Benefits of PIPAC vs. HIPEC
Which type of chemotherapy will most benefit a patient depends on a number of factors, such as their cancer cell type, stage, overall health, and others. However, both treatments offer a range of potential benefits.
PIPAC Benefits
PIPAC is a minimally invasive treatment. It doesn’t require large incisions or long hospital stays, which often leads to an easier recovery than major surgery or standard chemotherapy.
PIPAC can also help reduce ascites, which is the buildup of fluid in the abdomen. Ascites can cause swelling, belly pain, and shortness of breath.
Research published in the Annals of Surgical Oncology showed that nearly half (46%) of mesothelioma patients were able to get their ascites under control after PIPAC.
Another important benefit is that PIPAC can be repeated. This makes it useful for patients whose cancer cannot be removed or when HIPEC would be too risky. Repeating this treatment over time can help control symptoms and slow cancer spread. In some cases, PIPAC may shrink or control tumors enough that HIPEC surgery becomes possible later on.
PIPAC was first developed in France and is now used in specialized cancer centers and clinical trials worldwide. Studies have shown it to be safe for peritoneal mesothelioma and several other abdominal cancers.
HIPEC Benefits
One of the key benefits of HIPEC is helping some patients live longer, especially when compared with chemotherapy alone.
HIPEC allows heated chemotherapy to be placed directly into the abdomen after visible tumors are removed. This targeted approach helps treat cancer cells that may be left behind and are too small to see. Since the chemotherapy drugs stay mostly in the abdomen, they can work more effectively against the cancer while limiting how much it affects the rest of the body.
If you’re unsure whether HIPEC or PIPAC may be right for you, talking with a specialist who treats peritoneal mesothelioma regularly can help clarify your options.
Use our Free Doctor Match service to connect with mesothelioma specialists who offer advanced treatments like HIPEC and PIPAC.
Treatment Side Effects of PIPAC vs. HIPEC
Chemotherapy in general can affect the whole body, even when it’s placed directly into the abdomen versus administered through an IV. Some side effects come from the chemotherapy itself, while others are related to the type of procedure used to deliver the treatment.
Side Effects of PIPAC
PIPAC is less invasive than HIPEC and is usually easier to tolerate. It uses small incisions, which lowers the stress on the body. It can still cause side effects, but they are often milder than with traditional chemotherapy.
Possible side effects of PIPAC include:
- Constipation or diarrhea
- Low-grade fever
- Mild nausea
- Short-term inflammation or fluid buildup in the abdomen
- Temporary abdominal pain or soreness
Most side effects from PIPAC improve within a few days. Overall, PIPAC tends to have lower toxicity and fewer whole-body side effects compared with standard chemotherapy, making it a helpful option for patients who can’t have major surgery.
Side Effects of HIPEC
HIPEC is done during major abdominal surgery, so recovery can be more time-consuming. Many patients experience fatigue as their body heals, and some need extra time to regain their strength.
Possible side effects of HIPEC include:
- Bowel or digestive problems
- Changes in digestion or appetite
- Fatigue and general weakness
- Longer hospital stays
- Risk of infection after surgery
- Temporary changes in memory, sometimes called chemo brain
Because HIPEC is a major surgical procedure, doctors carefully select patients who are healthy enough to tolerate these risks.
Survival Rates for PIPAC vs. HIPEC
Survival outcomes for peritoneal mesothelioma can vary widely from person to person. Factors such as how far mesothelioma tumors have spread, the cancer cell type, and a patient’s overall health all play an important role.
Clinical research shows the following trends:
- PIPAC leads to disease stabilization in 60-80% of patients, along with improved quality of life and extended overall survival for cases where surgery isn’t initially an option, according to a review published in Cancers.
- HIPEC leads to a median survival of 3 to 5 years for select patients, with some living 7 to 10+ years, according to reports from the Journal of Clinical Oncology and the Annals of Surgical Oncology.
HIPEC is still considered the strongest option for long-term survival when tumors can be safely removed. However, PIPAC is becoming an important part of treatment plans for patients who can’t have surgery or who need palliative care for symptom relief.
Combining HIPEC and PIPAC With Other Mesothelioma Treatments
Doctors often treat peritoneal mesothelioma using a multimodal approach, which means combining more than one type of treatment over time. This may include surgery, chemotherapy, and sometimes immunotherapy.
Examples of how these treatments may be combined include:
- IV chemotherapy may be given before or after HIPEC.
- PIPAC may be used alongside IV chemotherapy.
- PIPAC may be used first, with surgery and HIPEC performed later if the cancer stabilizes.
- Repeat PIPAC treatments may be used to manage symptoms.
- Immunotherapy may be added to help the immune system fight cancer.
Using different therapies at different stages allows care teams to adjust treatment goals, whether the focus is on slowing cancer growth, relieving symptoms, or extending survival.
Learn more about different treatments and the specialists who offer them in our Free Peritoneal Mesothelioma Guide.
Get Help Finding the Right Mesothelioma Treatment
Knowing which treatments may fit your situation can feel overwhelming, especially after a new diagnosis. Mesothelioma Hope is here to support you and your family as you make these decisions.
Our Patient Advocates work one-on-one with families to answer questions and help them feel more confident about what comes next.
We can help you:
- Find doctors and cancer centers experienced with HIPEC and PIPAC
- Understand whether you may be a candidate for certain treatments
- Explore financial assistance for your medical care and travel
- Connect with support groups and other resources
Call (866) 608-8933 or download our Free Peritoneal Mesothelioma Guide to learn more about treatment options and what to expect.
PIPAC vs. HIPEC FAQs
What is the difference between HIPEC and PIPAC surgery?
HIPEC and PIPAC both deliver chemotherapy directly into the abdomen, but they are very different procedures. HIPEC is done during major surgery, where doctors first remove visible tumors and then circulate heated chemotherapy inside the abdomen. Recovery from HIPEC can take weeks as it involves extensive surgery.
PIPAC is much less invasive. It uses small incisions and a camera to deliver chemotherapy as a fine pressurized mist. Tumors are not removed during PIPAC, and recovery is usually quicker, often within days.
How does PIPAC compare to other treatments?
PIPAC is different from standard chemotherapy because it delivers medication directly to the abdominal lining instead of through the bloodstream. This targeted approach often leads to fewer whole-body side effects.
PIPAC is most often used when mesothelioma surgery is not an option or if the cancer has returned after other treatments. While it is not meant to cure the disease, it can help slow cancer growth, reduce symptoms like fluid buildup (peritoneal ascites), and improve quality of life.
Is HIPEC better than traditional chemo?
For some patients, yes. HIPEC can be more effective than traditional chemotherapy alone when the cancer can be surgically removed. By combining tumor removal with heated chemotherapy placed directly in the abdomen, HIPEC targets cancer cells more directly.
Traditional chemotherapy travels through the bloodstream and affects the whole body. For carefully selected patients, studies show HIPEC can lead to longer overall survival compared with chemotherapy alone. However, it is not suitable for everyone since it requires major surgery.
Is PIPAC better than HIPEC for mesothelioma?
PIPAC is not better or worse than HIPEC overall. Each treatment is used for different situations. HIPEC is usually recommended when mesothelioma doctors can safely remove most of the cancer and the patient is healthy enough for surgery.
PIPAC is better suited for patients who cannot undergo major surgery, have advanced cancer, or need a treatment that can be repeated with fewer side effects. The best option depends on the individual patient’s condition and treatment goals.
Can you get PIPAC and HIPEC?
Yes. Some mesothelioma patients receive both treatments at different points in their care. PIPAC may be used first to help slow cancer growth, reduce fluid buildup, or improve symptoms.
If the cancer becomes more stable and the patient’s health allows, doctors may later recommend surgery followed by HIPEC. This approach is not right for everyone, but it can be an option in certain cases.
How do doctors choose between PIPAC and HIPEC?
Doctors look at how far the cancer has spread, whether tumors can be safely removed, and how well the patient might tolerate surgery. Imaging scans and sometimes a minor video-assisted surgery can help doctors see the cancer more clearly and guide their treatment decisions.
Doctors also talk with patients and families about their treatment goals to determine whether the focus should be on long-term survival or symptom relief.
Does insurance cover PIPAC or HIPEC?
HIPEC is widely available at major U.S. cancer centers and is covered by most insurance plans when medically necessary. PIPAC is newer and not yet available everywhere, but many insurance providers cover it when offered through participating cancer centers or clinical trials.
If you’re unsure about coverage, a hospital financial counselor can review your plan and help you understand all your options. You may also qualify for financial assistance to help cover your treatments and travel expenses.
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