Clinical Updates on the Treatment of Advanced Cholangiocarcinoma - Episode 6
GI oncologists react to a prognosis for patients with newly diagnosed advanced cholangiocarcinoma and discuss how they counsel patients on goals of care and treatment expectations.
John L. Marshall, MD: Gang, how are we doing with this disease so far? We have increased recognition, more diagnoses, multidisciplinary care to get patients resected. With adjuvant therapy, there are some standards now. Are we doing better?
Milind Javle, MD: I think so. We are seeing these patients, particularly for intrahepatic cholangiocarcinoma, for much longer than we ever did before. I’m not sure the prognosis has changed that much for perihilar or gallbladder cancer, but I think there are many options. There are promising clinical trials, and being in this business, you’ve got to be an optimist.
John L. Marshall, MD: There is that patient I see now who has what I call smoldering, quiet cholangiocarcinoma, where they may go 2, 3, 4 years with systemic therapy, liver-directed therapies, resections here and there. It feels like in that subgroup, we’re doing OK. Then there’s the other kind that feels more like pancreatic cancer; that’s a mean cancer and grows faster. Do you all see that same pattern in your patient base? Katie?
R. Kate Kelley, MD: I see enormous heterogeneity, and a lot of it is linked to the anatomy and how compromised the liver is by the tumor. Patients who have poor drainage and poor liver function out of the gate that we don’t successfully decompress have a very poor prognosis, while patients whose livers are working well and whose tumors aren’t impinging on a major duct do much better. You’re right, there’s biologic heterogeneity and that anatomic heterogeneity that I mentioned.
I saw a patient yesterday who is on her seventh line of systemic therapy, various iterations of gemcitabine, as well as 5-FU [fluorouracil] and the partner drugs. I’ve been treating her for 7 or 8 years now, and she has metastatic intrahepatic cholangiocarcinoma. There’s a huge spread of possibilities, and I do tell patients that, while the median survival from our phase III data tends to be still less than a year, we’re looking eagerly to this ongoing SWOG trial of GEM/CIS/Abraxane [gemcitabine, cisplatin, paclitaxel] vs GEM/CIS [gemcitabine, cisplatin] to see if we might change that benchmark. The median remains less than a year. Unlike a lot of other GI [gastrointestinal] cancers, the standard deviation is huge. There’s a much bigger splay in the possibilities.
John L. Marshall, MD: Maybe that goes back to our biology differences, and we may be able to figure that out at some point and not just let it play out in front of us. Sameek?
Sameek Roychowdhury, MD, PhD: I was going to add to what Katie and Milind have said. The idea that these patients have good hope and outcomes is there, it’s true. I have found myself keeping other people away from these patients who are thinking there is no hope or chance for long-term survival. I have to be very aggressive about making sure we unblock the ducts because when someone has a blocked duct and a problem, that’s going to impair ability to treat them, but it’s not the end of the world, right? You keep trying. Sometimes you unblock it from below with a stent, through ERCP [endoscopic retrograde cholangiopancreatography]. Sometimes you unblock it from the top, or sometimes you do both. Then you find a way to get them therapy. One thing I’ve seen is dismissal, like this diagnosis means there’s no hope. That’s not true at all. I advocate and push. When my patients get hospitalized, it’s not uncommon for me to have to push people to go beyond what they’re looking at. We have effective therapies; this is just a blocked duct, and we have to get them past this blockage. One thing I’ve learned is that we have to work with our colleagues and show them, “You know what, this patient could be here 5 years from now; we just have to get past this duct.”
John L. Marshall, MD: I agree. There is a battle we have with our colleagues who want to have that “goals of care” discussion from the get-go when we can turn these folks around. On the flip side, these patients can get complicated quickly. Katie alluded to external biliary drains—they can be high output or get dehydrated. You can watch them melt in front of you, so they do require additional support. This is not a casual patient who you see once a month. They take a lot of management and maintenance, and it speaks to the quality of life that these folks go through. We do ask a lot of our patients. This particular group has to go through a lot, but many of them are willing. With the right support, including palliative care, we can have a positive output and outcome for our patients.
Transcript Edited for Clarity