Skip to main page content
U.S. flag

An official website of the United States government

Dot gov

The .gov means it’s official.
Federal government websites often end in .gov or .mil. Before sharing sensitive information, make sure you’re on a federal government site.

Https

The site is secure.
The https:// ensures that you are connecting to the official website and that any information you provide is encrypted and transmitted securely.

Access keys NCBI Homepage MyNCBI Homepage Main Content Main Navigation
Practice Guideline
. 2023 Jul 25;30(8):7132-7150.
doi: 10.3390/curroncol30080517.

A Practical Guide for the Systemic Treatment of Biliary Tract Cancer in Canada

Ravi Ramjeesingh  1 , Prosanto Chaudhury  2 , Vincent C Tam  3 , David Roberge  4 , Howard J Lim  5 , Jennifer J Knox  6 , Jamil Asselah  7 , Sarah Doucette  8 , Nirlep Chhiber  8 , Rachel Goodwin  9
Affiliations
Practice Guideline

A Practical Guide for the Systemic Treatment of Biliary Tract Cancer in Canada

Ravi Ramjeesingh et al. Curr Oncol. .

Abstract

Biliary tract cancers (BTC) are rare and aggressive tumors with poor prognosis. Radical surgery offers the best chance for cure; however, most patients present with unresectable disease, and among those receiving curative-intent surgery, recurrence rates remain high. While other locoregional therapies for unresectable disease may be considered, only select patients may be eligible. Consequently, systemic therapy plays a significant role in the treatment of BTC. In the adjuvant setting, capecitabine is recommended following curative-intent resection. In the neoadjuvant setting, systemic therapy has mostly been explored for downstaging in borderline resectable tumours, although evidence for its routine use is lacking. For advanced unresectable or metastatic disease, gemcitabine-cisplatin plus durvalumab has become the standard of care, while the addition of pembrolizumab to gemcitabine-cisplatin has also recently demonstrated improved survival compared to chemotherapy alone. Following progression on gemcitabine-cisplatin, several chemotherapy combinations and biomarker-driven targeted agents have been explored. However, the optimum regimen remains unclear, and access to targeted agents remains challenging in Canada. Overall, this article serves as a practical guide for the systemic treatment of BTC in Canada, providing valuable insights into the current and future treatment landscape for this challenging disease.

Keywords: adjuvant therapy; biliary tract cancer; cholangiocarcinoma; gallbladder carcinoma; immunotherapy; neoadjuvant therapy; systemic therapy; targeted therapy.

PubMed Disclaimer

Conflict of interest statement

R.R. has received honoraria and served on advisory boards for Amgen, Eisai, AstraZeneca, Ipsen, Merck, Incyte, and Roche; has received funded grants from Amgen, Eisai, AstraZeneca, Ipsen, and Pfizer; and has participated as an investigator in clinical trials supported by Merck, AstraZeneca, Ipsen, Incyte, and Nucana. P.C. has received honoraria from Astellas Pharma, Merck, AstraZeneca, and Ipsen. V.C.T. has received honoraria and served on advisory boards for AstraZeneca, Eisai, Incyte, Ipsen, Merck, and Roche; has received institutional research funding from AstraZeneca, Eisai, Ipsen, and Roche; and has received institutional clinical trial funding from AstraZeneca, Basilea, Exelixis, Merck, and Roche. D.R. has received honoraria from Siemens Healthineers, Recordati, Roche, Accuray, Varian Medical Systems, Elekta, Novocure, and AstraZeneca, and has investments in Croton Healthcare, AFX Medical, and MisoChip. H.J.L. has received honoraria from Eisai, Taiho, Merck, Lilly, Bristol Meyers Squibb, and Amgen for consultant work and has participated as an investigator on clinical trials supported by Bayer, Bristol Meyers Squibb, Lilly, Roche, AstraZeneca, and Amgen. J.J.K. has received honoraria from AstraZeneca, Merck, Roche, Eisai, Pfizer, Ipsen, and Incyte for consultant work and has received grant or research support from AstraZeneca, Ipsen, Merck, and Roche. J.A. has no conflicts of interest to declare. S.D. has received funding from AstraZeneca Canada for medical writing services. N.C. has received funding from AstraZeneca Canada for medical writing services. R.G. has received honoraria and served on advisory boards for Amgen, AstraZeneca, Bayer, Roche, Merck, Novartis, Ipsen, AAA, Eisai, Apobiologix, Incyte, Pfizer, Mylan, and Taiho and has received grant support from Apobiologix, Ipsen, Novartis, Pfizer.

Figures

Figure 1
Figure 1
Summary of systemic treatment landscape for advanced unresectable or metastatic biliary tract cancers in Canada. BTC, biliary tract cancer; CADTH, Canadian Agency for Drugs and Technology in Health; iCCA, intrahepatic cholangiocarcinoma; dCCA, distal cholangiocarcinoma; pCCA, perihilar cholangiocarcinoma; FOLFOX, folinic acid, fluorouracil, oxaliplatin.
Figure 2
Figure 2
Proposed algorithm for systemic treatment of biliary tract cancer. * Eligibility for resection is based on a number of factors, including presence of distant metastasis, vascular invasion, feasibility of reconstruction, expected volume and function of liver remnant, and performance status. It should be assessed by a hepatobiliary surgeon in consultation with a multidisciplinary team. † Genomic profiling can be considered using surgical specimen given the high rate of recurrence in these patients. ‡ Should be considered in patients with pCCA and remains investigational for iCCA. § Durvalumab is currently the only immunotherapy agent with a Health Canada indication for treatment of patients with advanced or metastatic BTC. Pemigatinib is currently the only FGFR2 with a Health Canada indication in BTC that is marketed in Canada. BTC, biliary tract cancer; Gem-Cis, gemcitabine-cisplatin; R1, residual disease; SBRT, stereotactic body radiation therapy; TACE/TARE, Transarterial chemoembolization/Transarterial radioembolization.
See this image and copyright information in PMC

References

    1. Banales J.M., Marin J.J.G., Lamarca A., Rodrigues P.M., Khan S.A., Roberts L.R., Cardinale V., Carpino G., Andersen J.B., Braconi C., et al. Cholangiocarcinoma 2020: The next horizon in mechanisms and management. Nat. Rev. Gastroenterol. Hepatol. 2020;17:557–588. doi: 10.1038/s41575-020-0310-z. - DOI - PMC - PubMed
    1. Lamarca A., Edeline J., Goyal L. How I treat biliary tract cancer. ESMO Open. 2022;7:100378. doi: 10.1016/j.esmoop.2021.100378. - DOI - PMC - PubMed
    1. Baria K., De Toni E.N., Yu B., Jiang Z., Kabadi S.M., Malvezzi M. Worldwide Incidence and Mortality of Biliary Tract Cancer. Gastro Hep Adv. 2022;1:618–626. doi: 10.1016/j.gastha.2022.04.007. - DOI - PMC - PubMed
    1. Van Dyke A.L., Shiels M.S., Jones G.S., Pfeiffer R.M., Petrick J.L., Beebe-Dimmer J.L., Koshiol J. Biliary tract cancer incidence and trends in the United States by demographic group, 1999–2013. Cancer. 2019;125:1489–1498. doi: 10.1002/cncr.31942. - DOI - PMC - PubMed
    1. Miranda-Filho A., Piñeros M., Ferreccio C., Adsay V., Soerjomataram I., Bray F., Koshiol J. Gallbladder and extrahepatic bile duct cancers in the Americas: Incidence and mortality patterns and trends. Int. J. Cancer. 2020;147:978–989. doi: 10.1002/ijc.32863. - DOI - PMC - PubMed

Publication types

LinkOut - more resources