Bile Duct Cancer Awareness Month - Q & A Session with an Expert
This interview was originally published in www.oncofocus.com on 27th February 2020
Dr. Tang Weng Heng is a leading Clinical Oncologist in Malaysia. We would like to thank him for taking out time from his busy schedule to share with us his thoughts and experiences on diagnosis, treatment, and management of bile duct cancer. We hope this interview will help our readers understand this rare but highly aggressive cancer.
Besides people having a family history, other people who are at high risk of bile duct cancer are people with chronic liver disease, chronic hepatitis, patients who have a history of recurrent infection of the bile duct called as “recurrent cholangitis.
We understand that most cancers are manageable if they are identified at an early stage. So, for bile duct cancer, what are the early signs and symptoms one should look for early diagnosis?
Dr. Tang: The typical sign and symptom for bile duct cancer would be jaundice or abdominal pain. In some patients, stool may turn pale in color, or urine may become darker in color. Patients who have an unexplained weight loss of more than 10% of their body weight should get investigated for any possible cancer, including bile duct cancer.
How can we improve the early diagnosis of bile duct cancer?
Dr. Tang: In patients with a family history of bile duct cancer or gall bladder cancer, ultrasound screening of the abdomen could be helpful in early diagnosis. Please note that the abdomen ultrasound is a non-invasive procedure that does not involve any radiation. It can be easily done, and it is widely available, and the result is quick.
If anything peculiar is found in ultrasound, then we need to proceed with a confirmatory test like a CT scan, a blood test that would include liver function, tumor marker like CA199. If something is of concern, the patient may have to undergo a biopsy procedure to confirm the diagnosis.
Who are at risk of developing bile duct cancer?
Dr. Tang: Besides people having a family history, other people who are at high risk of bile duct cancer are people with chronic liver disease, chronic hepatitis, patients who have a history of recurrent infection of the bile duct called “recurrent cholangitis.”
People who live in certain endemic areas in Thailand are prone to have “liver fluke”- chronic parasitic infection of the gall bladder and bile duct. These people are at higher risk of acquiring bile duct cancer. Apart from this, patients having autoimmune diseases like primary sclerosing cholangitis would be at the risk of developing bile duct cancer.
Bile duct cancer is a relatively rare and aggressive cancer when compared to other cancers. It gets detected only in the advanced stage and the only way forward is by improving the prognosis.
What are the major types of bile duct cancer?
Dr. Tang: The medical terminology for bile duct cancer would be cholangiocarcinoma. Cholangiocarcinoma can be classified into two: intrahepatic (inside the liver) and extrahepatic (outside the liver) cholangiocarcinoma. Perihilar bile duct cancer is also known as perihilar cholangiocarcinoma and is found in the hilum region, the area where the right and left bile ducts exit the liver and join to form the common hepatic duct.
What are the prognosis and common treatment options for treating bile duct cancer?
Dr. Tang: For any cancer, the prognosis of the patient would be dependent on the stage; the earlier the diagnosis, the better is the prognosis. The chances of survival with stage-one bile duct cancer would be 90%. Unfortunately, very few patients are diagnosed at this stage. Most of the patients are diagnosed at a more advanced stage, which has a survival rate of less than 5%.
In early-stage bile duct cancer, the only curative treatment option would be surgery to remove cancer entirely. The patients who are ineligible for surgery due to the location or the size of the tumor would need to undergo chemotherapy to downstage cancer and then go for surgery to remove the tumor.
Immunotherapy as a treatment option is yet to be investigated for bile duct cancer. It is only applicable for patients with a certain kind of genetic abnormality in the tumor that causes cancer. One of the methods that we use to treat patients with bile duct cancer is next-generation sequencing of the tumor DNA. The results would help us to identify the most appropriate chemo or immunotherapeutic medication that would help the patient. Next-generation sequencing also helps us to determine if the tumor has microsatellite instability. Patients who have microsatellite instability have high chances of responding to immunotherapy.
Does the Malaysian government provide any financial assistance for bile duct cancer treatment?
Dr. Tang: Newer treatment options or diagnostic methods would have a lot of financial implications. As mentioned earlier, NGS and immunotherapy are very costly. Fortunately, for some patients, medical insurance will cover these treatments. However, low-income group patients will not be able to go for immunotherapy or NGS.
What interesting trends do you foresee for bile duct cancer diagnosis and treatment?
Dr. Tang: Bile duct cancer is a relatively rare and aggressive cancer when compared to other cancers. It gets detected only in the advanced stage and the only way forward is by improving the prognosis. The improvement of treatment outcomes for bile duct cancer patients would require a collaborative effort and pooling of knowledge and experience of multiple experts from several countries.
It was an insightful discussion. Thank you for your time and your valuable inputs. I am sure that this interview will help in increasing awareness!
Dr. Tang: Thank you!