Treatment options for biliary cancer
Your treatment options for biliary cancer depends on the size, location, and stage of the tumour. You should be fully informed and involved in decisions about your treatment options.
Your treatment will depend upon the size, location, and stage of the tumour, as well as your general health and fitness. The choice of treatments will be discussed with you and your preferences will be considered. Your treatment will be discussed by a multidisciplinary team (MDT), which means that experts in different areas of cancer treatment (e.g. surgeons, gastroenterologists, radiologists, oncologists and nurses) come together to share their expertise in order to provide the best patient care.
Surgery to remove the tumour (resection) is the only potentially curative treatment for biliary tract cancer.
The aim of resection is to remove the cancer, along with a healthy margin of tissue, to help stop it from coming back. Curative surgery is usually only offered to patients with early-stage (localised) disease, when there is a good chance of complete resection. The type of surgery will depend on the subtype of biliary tract cancer.
To remove an intrahepatic CCA, the surgeon must remove part of the liver. They will also remove nearby lymph nodes, which can be examined after the operation to see if the cancer has spread. The surgery may leave only a small amount of healthy liver, therefore a procedure called portal vein embolisation (PVE) might be used before surgery to reduce the risk of liver failure after resection. In PVE, blood flow to the area of liver containing the cancer is partially blocked off. This increases the size of the healthy part of the liver that will remain after surgery, by encouraging it to grow.
Resection of a hilar CCA involves removal of the bile duct containing the tumour as well as the common bile duct, part of the liver, the gallbladder and nearby lymph nodes. Part of the pancreas and duodenum might also be removed. The remaining bile ducts are re-joined to the intestine, and blood vessels that supply the liver might also have to be reconnected. PVE may be offered to patients before resection.
Surgery for extrahepatic CCA requires removal of the bile duct containing the tumour, nearby lymph nodes, part of the pancreas and part of the duodenum. The remaining pancreas and stomach are then reconstructed.
The extent of surgery required to remove tumours of the gallbladder depends on the location of the cancer within the gallbladder and how far it has spread. Tumours that are confined to one part of the gallbladder may be removed by resection of the gallbladder alone (called a cholecystectomy). If the cancer has spread throughout the gallbladder, the surgeon may remove the gallbladder, some nearby liver tissue and all the lymph nodes around the gallbladder. When incidental gallbladder cancer is discovered after a routine non-cancer operation (e.g. a person had a cholecystectomy for gallstones), a second operation may be organised to clear the area around the tumour, including part of the liver and the lymph nodes.
Ampullary cancer is typically removed by a type of surgery called pancreatoduodenectomy (also known as Whipple’s procedure). This involves removal of the head of the pancreas, part of the small intestine, the gallbladder and part of the bile duct.
Surgery can also be used to relieve some symptoms of biliary tract cancer. For example, tumours can
block the bile ducts and lead to a build-up of bile in the blood, causing jaundice, nausea and discomfort.
These blockages are commonly relieved by inserting a small tube (called a stent) into the bile duct to hold the duct open.
If insertion of a stent is not possible then surgery may be carried out to bypass the area of the blockage.
Chemotherapy destroys cancer cells and is widely used in the treatment of biliary tract cancer. You may read or hear about various types of chemotherapy. Some common terms about chemotherapy include adjuvant and neoadjuvant. The term adjuvant in this setting refers to additional therapies added to the primary therapy, e.g. adjuvant chemotherapy was given after surgery. Neoadjuvant therapy simply means that the additional therapy is provided prior to the primary therapy, e.g. neoadjuvant chemotherapy was given before surgery.
Adjuvant chemotherapy for resectable biliary tract cancer
Following surgical resection of biliary tract cancer, most patients will be offered adjuvant chemotherapy to reduce the risk of recurrence after surgery. Adjuvant chemotherapy has been shown to improve outcomes in patients with resected biliary tract cancer compared with no adjuvant treatment.
Chemotherapy for unresectable biliary tract cancer
Chemotherapy is typically used in the first-line treatment of biliary tract cancer that can’t be surgically removed. Patients with unresectable biliary tract cancer and who are in good general health, are typically offered chemotherapy as a treatment
Radiotherapy uses ionising radiation to damage the deoxyribose nucleic acid (DNA) of cancerous cells, causing them to die. Radiotherapy is not commonly used in the treatment of biliary tract cancer, but may be considered for some patients. Radiotherapy can be used to relieve some symptoms of biliary tract cancer. For example, if a tumour can’t be removed, radiotherapy can help to relieve pain and other symptoms by shrinking tumours that block blood vessels or bile ducts or press on nerves
If a tumour is blocking a bile duct, it can lead to jaundice, nausea, loss of appetite and serious problems such as infection and liver failure. Blockages are commonly relieved by inserting a small metal or plastic tube (stent) to hold the bile duct open and allow bile to flow freely again. Stents are inserted into the blocked bile duct during ERCP, or through the skin by a procedure called percutaneous transhepatic cholangiography (PTC), in which a long thin needle is passed through the skin and liver into the bile duct. Ultrasound or X-ray is used to help guide the needle to the blockage, then a wire is passed down the needle into the bile duct to guide the stent into place.
Stents can themselves get blocked, usually due to a build-up of bile in the stent. If this happens, another stent can be inserted. There is also a risk of infection with stents, which is usually caused by the stent getting blocked. This can lead to biliary sepsis, which is a potentially life-threatening condition, so infection must be treated quickly. It is important that you report any signs of infection (e.g. abdominal pain, aching muscles, high temperature or shivering) to your treating team, doctor or nurse immediately. The infection can be treated with antibiotics and the stent can be replaced.
You may be eligible to take part in a clinical trial, so it is always a good idea to ask your care team if there is a trial suitable for your condition.
Being involved in a clinical trial has the benefits of allowing you access to the latest treatments before they become generally available. This is often combined with closer monitoring of your care and condition.
For further information on the latest upper GI cancer trials visit the Australian Gastro-Intestinal Cancer Trials Group (AGITG) website: https://gicancer.org.au/about-the-agitg/ or visit the Australian Cancer Clinical trials website: www.australiancancertrials.gov.au
> Learn more about clinical trials
Being referred to a specialist centre
Anyone diagnosed with biliary cancer should have their case reviewed at a centre where there is a specialist multidisciplinary team of doctors and allied health professionals, who are able to assess and treat the disease.
Depending on your treatment, your treatment team may consist of a number of different health professionals, such as:
- General Practitioner – your GP looks after your general health and works with your specialists to coordinate treatment.
- Gastroenterologist- specialises in diseases of the digestive system, can also perform endoscopy procedures.
- Upper gastrointestinal (UGI) surgeon- specialises in surgery to treat diseases of the upper gastrointestinal system.
- Medical oncologist – prescribes and coordinates chemotherapy treatment.
- Radiation oncologist- prescribes and coordinates radiation therapy treatment.
- Cancer nurses – assist with treatment and provide information and support throughout your treatment.
- Other allied health professionals- such as dietitians, exercise physiologists, social workers, pharmacists, speech pathologists and counsellors.