Comparing Standard Intraperitoneal (IP) Chemotherapy, HIPEC, and PIPAC

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There is no single "best" way to deliver chemotherapy directly into the abdominal cavity. Today, doctors have several approaches that may be used depending on a patient's cancer type, possibility of complete surgical removal (operability), how far the disease has spread, treatment goals, and overall health.

Standard intraperitoneal (IP) chemotherapy, hyperthermic intraperitoneal chemotherapy (HIPEC), and pressurized intraperitoneal aerosol chemotherapy (PIPAC) all deliver chemotherapy directly to the abdominal cavity where cancers may spread. However, each treatment differs in how the chemotherapy is delivered, when it is used, who may benefit, and the goals of treatment.

For example, HIPEC is typically performed once following cytoreductive surgery (CRS) after all visible tumors have been removed. Standard IP chemotherapy is delivered through an implanted catheter over multiple treatment sessions, often alongside intravenous (IV) chemotherapy. PIPAC is a newer, minimally invasive approach that delivers chemotherapy as a fine mist during laparoscopy and can be repeated over time. It is most commonly used for patients with advanced peritoneal cancer that cannot be completely removed with surgery.

Because these treatments are designed for different situations, they should not be viewed as competing options. Instead, they are different tools that may be appropriate at different points in a patient's cancer journey. Understanding how they compare can help patients and caregivers have more informed conversations with their healthcare team about which approach, if any, may be appropriate for their individual circumstances.

How Does Surgery Fit Into Treatment?

While Standard IP chemotherapy, HIPEC, and PIPAC each deliver chemotherapy directly into the abdomen, they are often used alongside surgery rather than replacing it.

For patients who are healthy enough and whose cancer can be safely removed, cytoreductive surgery (CRS) is often the cornerstone of treatment. The goal of CRS is to remove all visible tumors from the abdominal cavity. Research has consistently shown that achieving a complete cytoreduction—meaning no visible cancer remains at the end of surgery—is one of the most important factors associated with better outcomes for many patients with peritoneal metastases.

After surgery, additional treatments such as HIPEC, standard IP chemotherapy, or systemic (IV) chemotherapy may be recommended to target cancer cells that are too small to see. For patients whose cancer cannot be completely removed with surgery, treatments like PIPAC or standard IP chemotherapy may help slow disease progression, relieve symptoms, and improve quality of life.

Not every patient is a candidate for every treatment. Your healthcare team will recommend a personalized treatment plan based on your type of cancer, the extent of disease, your overall health, and your treatment goals.

How are Standard IP Chemotherapy, HIPEC, and PIPAC similar and different?

This table highlights the similarities and differences between these three approaches, including how they are given, who they are intended for, their potential benefits, and the current evidence supporting their use.

It is important to note that “HIPEC” is often used as a shorthand way to refer to the complete procedure of cytoreductive surgery with HIPEC (CRS/HIPEC), but it specifically references the heated chemotherapy component of the procedure.

Standard IP Chemo

Key Advantages:

Less invasive than surgery-based approaches
Combines systemic and local exposure

Key Limitations:

Less potent
Common complications with the IP catheter

HIPEC

Key Advantages:

High local drug concentration
Heat-enhanced cancer-fighting effects
Potential curative intent

Key Limitations:

Highly invasive with more complications
Often limited to a select patient population

PIPAC

Key Advantages:

Minimally invasive
Can be repeated as directed by your physician
Localized treatment area

Key Limitations:

Palliative intent only
No standard protocol
Evolving data on efficacy with limited long-term data

Feature	Standard IP Chemo	HIPEC	PIPAC
Delivery Method	Catheter or port-based liquid chemo infusion	Heated liquid chemo bath in the abdomen	Laparoscopic fine aerosol spray under pressure
Tissue Penetration	Low	Moderate-High (enhanced by heat and concentration)	Moderate (improved by pressure)
Surgical Requirement	None (port can be placed by Interventional Radiology (IR))	Major surgery (usually cytoreductive surgery)	Minimally invasive laparoscopy
Temperature Used	Normothermic (room temp/not heated)	Hyperthermic (41-43°C)	Normothermic (room temp/not heated)
Pressurized	No	No	Yes
Treatment Setting	Outpatient infusion center	Surgery and hospital stay	Repeated laparoscopic procedures
Treatment Frequency	Repeated cycles over weeks / months	Usually single procedure, Can be performed multiple times as needed for recurrence	Multiple sessions at regular intervals; usually every 4-8 weeks
Treatment Invasiveness	Low	High (largely due to CRS component)	Low to moderate
Typical Treatment Intent / Clinical Uses	Adjuvant (preventative) or palliative disease control	Potentially curative in select patients	Palliative / disease control in advanced, unresectable cases
Hospital Stay	None (outpatient)	Extended postoperative stay (~2 weeks)	Short (same day or brief admission)
Systemic Toxicity	Moderate (depends on regimen)	Low-Moderate (mostly local exposure)	Low
Common Cancers Treated	Ovarian, select GI cancers	Peritoneal metastases from various primaries including appendix, colorectal, ovarian, and peritoneal mesothelioma	Peritoneal metastases from various primaries (currently under investigation)
Repeatability	High (designed for multiple treatments)	Limited (only in select patients)	High (designed for multiple treatments)
Recovery Time	Minimal	Long (weeks - months)	Short (days)