The Evolving Treatment Landscape of Biliary Tract Cancers

Closing out their discussion on biliary tract cancers, expert panelists share key takeaways and excitement for the evolving treatment paradigm.


Milind M. Javle, MD: For our closing remarks, let me start with you, Dr Rocha. Given these strategies and findings in biliary tract cancer, what are you excited about and what are you looking forward to?

Flavio G. Rocha, MD, FACS, FSSO: Thank you, Dr Javle. I’m very excited. All these developments that we see—in the advanced setting, the targeted setting, and the mutational landscape—I want to bring up front. I want to use that information in the localized setting and the surgical resection setting. There’s been lots of press about MSI [microsatellite instability]–high tumors, mainly in colon cancer, but we know that there’s a defined subset in cholangiocarcinoma. You have a nice study looking at that incidence. It’s still low, about 1.8%, but a Spanish registry study looked at about 6% incidence. These patients respond very well to immunotherapy. It’s 1 of those tumor-agnostic approvals, so we’re starting to use that for patients in the preoperative setting. There’s been a lot of movement toward nonoperative management of some of these tumors in other sites. I don’t think we’re there, but when we’re resecting these patients, we’re getting pathologic complete response rates or major response rates.

As we identify these targets and find new drugs, we’re going to expand the indications for surgery. For patients who were thought to be out of the box, with disease outside, if we have a good drug for immunotherapy, then they’re more willing to take to the operating room, be aggressive, and use the combination therapy. The same thing goes for locoregional therapy. We put chemotherapy in the pump. What if we put immunotherapy in the pump? How does immunotherapy with the pump therapy make a difference? With that, I’ll hand it off to Dr Koay.

Milind M. Javle, MD: Thank you, Dr Rocha. I want to mention an abstract by…that looked at a profile of MSI-high cholangiocarcinoma. It’s an interesting subset. Hopefully we’ll get some information on that subset. Dr Koay, in terms of locoregional therapy, what are you excited about?

Eugene J. Koay, MD, PhD: There’s so much to be excited about. Just as Dr Rocha has the excitement about bringing the molecular and targeted therapies up front, we’re thinking that locoregional therapies can be taken from the intermediate stages to more advanced stages, in combination with not only systemic targeted therapies vs traditional cytotoxics but also other locoregional therapies. It comes down to understanding the molecular drivers of a patient’s disease and the clinical aspects whenever you have this high-quality imaging. Even if you have all these molecular aspects, you have to take in the full picture of the patient. The onus is on us to figure out how we select these patients for the right therapy. There are many questions. As a researcher, this is what gets you excited and it makes it fun. You get to work with great individuals, intellectuals like yourselves, and others in the field, so you come up with innovative trial designs and research questions that hopefully will drive the field forward.

Milind M. Javle, MD: Dr Shroff, immunotherapy with checkpoint inhibitors is here to stay. I’m excited about seeing how we can make cold tumors hot, how we can use targeted therapies to make tumors more immunogenic, and how we can impact NASH [nonalcoholic steatohepatitis] and other aspects of cholangiocarcinoma. Could you add a final comment about what you might see in the near future?

Rachna Shroff, MD: I treat pancreatic and biliary cancer, so I’ve been an immunotherapy skeptic. But I’m excited to have been proven wrong. There’s much more we can do in that space in terms of combinatorial approaches with immunotherapy and how we can build on the fantastic backbone that we have. There’s a lot to be said as we get better at precision oncology about doing a deeper dive into resistance mechanisms, so we can start to develop the next generation of not only FGFR inhibitors but each of the new targets that we’re learning about. That way, we can always be ahead of the game and be proactive in the drug development space. It’s wonderful to see the commitment to developing drugs in biliary cancer because it’s been an incredible change from a decade ago.

Milind M. Javle, MD: Thank you, Dr Shroff. I don’t know about you, but I enjoyed this discussion with my colleagues here. Thanks to all of you. To our viewing audience, we hope you found this OncLive® Peer Exchange® discussion to be useful and informative.

Transcript edited for clarity.

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