Treatment for Biliary Tract Cancer

Learning that you or a loved one has biliary tract cancer is difficult. You may feel overwhelmed by the medical terms and treatment choices. Treatment for biliary tract cancer has moved toward a personalized approach.¹

What is biliary tract cancer?

Biliary tract cancer is a rare type of cancer. It starts in the bile ducts or the gallbladder. Bile ducts are thin tubes that carry bile from your liver to your small intestine. Bile is a fluid that helps your body digest fats. Doctors often divide these cancers into different types based on where they start.^1,2

The most common type is cholangiocarcinoma. This cancer can start inside the liver or in the ducts outside the liver. Another type is gallbladder cancer. Most of these cancers are adenocarcinomas. This means they start in the gland cells of the biliary tract.^1,2

Who treats biliary tract cancer?

Many different experts work together to treat biliary tract cancer. This group is often called a multidisciplinary team. Your team may include:³

• Surgeon or surgical oncologist – A doctor who performs surgery to remove cancer.
• Radiation oncologist – A doctor who treats cancer with radiation therapy.
• Medical oncologist – A doctor who uses chemotherapy and other drugs to treat cancer.
• Gastroenterologist – A doctor who focuses on the digestive system.
• Hepatologist – A doctor who specializes in the liver and bile ducts.

Your team can also include other health professionals, such as:³

• Physician assistants (PAs)
• Nurse practitioners (NPs)
• Oncology nurses
• Social workers
• Pharmacists
• Counselors
• Registered dietitians (RDs)
• Physical therapists
• Occupational therapists

How is biliary tract cancer diagnosed?

Biliary tract cancer often does not cause symptoms in the early stages. Because of this, it is usually found when the disease is more advanced. Doctors use several tests to make a diagnosis.^2,4

Liver function tests

These blood tests help determine how well your liver is functioning and what might be causing your symptoms.⁴

Blood tests

Blood tests check how well your liver is working. Doctors also look for "tumor markers." These are substances in the blood that may be higher when cancer is present. One common marker for this cancer is CA 19-9.⁴

Imaging tests

Imaging tests help doctors see inside your body. They look for tumors or blocked ducts. Common tests include:^2,4

• Computed tomography (CT) scan – This uses X-rays to create detailed pictures of your organs.
• Magnetic resonance imaging (MRI) – This uses magnets and radio waves to see your biliary tract.
• Magnetic resonance cholangiopancreatography (MRCP) – This is a specific type of MRI that shows the bile ducts clearly without using dye.

ERCP and biopsy

Sometimes a doctor needs to look inside the ducts with a camera. This is called an endoscopic retrograde cholangiopancreatography (ERCP). During this test, the doctor may take a small sample of tissue. This is called a biopsy. A specialist looks at the tissue under a microscope to check for cancer cells.^2,4

Types of treatment for biliary tract cancer

The treatment you receive depends on the stage of the cancer. It also depends on your overall health.^1-4

Surgery

Surgery is the main treatment for cancer that has not spread. The goal is to remove the entire tumor. If the cancer is inside the liver, the surgeon may remove part of the liver. If the cancer is in the bile ducts, they may remove the affected tube.^1-4

Liver transplant

In specific cases, a liver transplant may be considered a treatment option, particularly for perihilar cholangiocarcinoma (a type of bile duct cancer that occurs where the left and right hepatic ducts join just outside the liver). This procedure involves the complete removal of the diseased liver, which is then replaced with a healthy liver from a donor.^1,3,4

After the surgery, patients must take lifelong medications to prevent their body from rejecting the new liver. While highly effective, there is still a risk that the cancer could recur after the transplant.⁴

Chemotherapy

Systemic therapy treats the whole body. Chemotherapy uses drugs to kill cancer cells. Often, doctors use a combination of 2 drugs called gemcitabine and cisplatin. Other common chemotherapy drugs include:^1,2,5

• Gemcitabine
• Cisplatin
• Capecitabine
• Oxaliplatin
• 5-fluorouracil (5-FU)

Radiation therapy

Radiation therapy uses high-energy beams to kill cancer cells. It may help shrink a tumor before surgery. Doctors also use it to help with pain or other symptoms.⁴

One common type is external beam radiation therapy (EBRT). This uses a large machine to aim rays at the cancer from outside the body. Another type is internal radiation. Doctors place tiny radioactive seeds or beads near the tumor.⁴

Immunotherapy

Immunotherapy helps your immune system find and attack cancer cells. Immunotherapy drugs are usually given along with chemotherapy for advanced biliary tract cancer. Some examples include:^2,6

• Keytruda® (pembrolizumab) – This drug can also be used with chemotherapy or on its own.
• Opdivo® (nivolumab) with Yervoy® (ipilimumab) – This combination may be used if the cancer has a high number of gene mutations.
• Imfinzi® (durvalumab) – This drug is often given with chemotherapy.

Targeted therapy

Every person has a unique type of cancer. Personalized medicine uses tests to look at the genes in your tumor. This is often called biomarker testing. These tests help doctors choose the best drugs for your specific needs, i.e., targeted therapy. This can make your treatment more effective.^1,7

Targeted therapy is for people with specific gene changes. Some examples of these drugs include:^1,7,8

• Pemazyre® (pemigatinib) – This treats cancers with a gene change called FGFR2.
• Lytgobi® (futibatinib) – This also targets FGFR2 gene changes.
• Tibsovo® (ivosidenib) – This is for people with an IDH1 gene mutation.
• Ziihera® (zanidatamab) – This drug is used to treat HER2-positive bile duct cancer that can’t be removed completely, or that has spread to other parts of the body.
• Bizengri® (zenocutuzumab-zbco) – This is approved for cancers with an NRG1 gene change.

What are the possible side effects?

Side effects can vary depending on the specific treatment you are taking. Common side effects include:^5-7

• Fatigue
• Nausea
• Diarrhea
• Loss of appetite

These are not all the possible side effects of biliary tract cancer treatments. Talk to your doctor about what to expect when taking these drugs. You also should call your doctor if you have any changes that concern you during treatment.^5-7

Before beginning treatment for biliary tract cancer, tell your doctor about all your health conditions. Tell them about any other drugs, vitamins, or supplements you are taking. This includes over-the-counter drugs.

When to contact your doctor

It is vital to watch for new symptoms. Call your doctor right away if you notice:²

• Jaundice – This is a yellow tint to your skin or the whites of your eyes.
• Dark urine – Your urine may look like the color of tea or cola.
• Light-colored stools – Your bowel movements may look grey or like clay.
• Fever or chills – This could be a sign of a bile duct infection.
• New pain – Watch for pain in the upper right side of your belly.

Work closely with your doctor

Biliary tract cancer is a complex disease, but there are many treatment options. Surgery, chemotherapy, and new targeted drugs offer hope to people with this condition. Work closely with your healthcare team to find the best plan for you. Always report new symptoms to your doctor immediately to manage your health effectively.