Treatments for unresectable biliary tract cancers

The following are treatment options for unresectable biliary tract cancers. Unresectable means the tumour cannot be removed completely with surgery. Your healthcare team will suggest treatments based on your needs and work with you to develop a treatment plan. These treatments are used to make you feel better and minimize growth of the tumour rather than to cure the cancer itself (also called palliative care) . They relieve symptoms such as jaundice and pain.

To make decisions that are right for you, ask your healthcare team questions about treatment.

For unresectable gallbladder or bile duct cancer, you will often be offered palliative surgery. This is used to control symptoms caused by cancer and improve quality of life. The surgical procedure that is done depends on several factors including the size of the tumour, where in the biliary tract it is located and your overall health.

Pallitative surgery may be the only treatment you have or it may be used along with other treatments.

Find out more about surgery for cancer and side effects of surgery.

You may be offered a stent or biliary bypass surgery to relieve a blockage caused by a tumour in the biliary tract.

A stent is a small metal or plastic tube placed into the bile duct that helps keep the bile duct open and allows bile to flow into the small intestine. The most common way to place a stent or catheter to relieve a bile duct blockage is with ERCP (endoscopic retrograde cholangiopancreatography) or PTC (percutaneous transhepatic cholangiography). Less commonly, stents may be placed through open surgery instead.

Biliary bypass is a procedure to create a path for bile to flow around a blockage in the bile duct. Biliary bypass is done through open surgery. The type of path a surgeon creates depends on the location of the blockage. Biliary bypass is done less often than stent placement.

A liver transplant is sometimes done for early-stage cholangiocarcinoma (CCA). It may be offered for intrahepatic cholangiocarcinoma (iCCA) or perihilar cholangiocarcinoma (pCCA) that is unresectable due to the location of the tumour.

In Canada, very few people are able to have a liver transplant for CCA. The number of donated livers is very small, so you will have to wait for one to become available that fits your needs. While you are on the waiting list for a transplant, you will have neoadjuvant chemotherapy or chemoradiation to slow the growth of the cancer. Unfortunately, by the time a donor liver is available, the cancer may have grown too much for the transplant to be possible or you may no longer be healthy enough to have the surgery.

If you have a liver transplant, you will need to take immunosuppressive medicines (immunosuppressants). These drugs are used to stop your body from rejecting the donated liver.

Chemotherapy uses drugs to destroy cancer cells. Many people with unresectable gallbladder or bile duct cancer will have chemotherapy, if their body is strong enough to cope with this treatment's side effects.

Chemotherapy may be the only treatment offered or it may be used along with other cancer treatments. Chemotherapy may be used to try to slow the growth of the cancer and control symptoms to improve how you feel.

The most common chemotherapy drug combination used for unresectable biliary tract cancers is cisplatin (or carboplatin) and gemcitabine with the immunotherapy drug durvalumab (Imfinzi). Other chemotherapy drug combinations that may be used include:

• cisplatin (or carboplatin) and gemcitabine
• cisplatin and capecitabine
• capecitabine and gemcitabine
• fluorouracil (also called 5-fluorouracil or 5-FU) and leucovorin
• leucovorin, fluorouracil and oxaliplatin

The most common chemotherapy drugs used for unresectable biliary tract cancers are:

• fluorouracil
• gemcitabine
• cisplatin

Find out more about chemotherapy and side effects of chemotherapy.

Radiation therapy uses high-energy rays or particles to destroy cancer cells. External radiation therapy (ERT) may be offered to relieve pain and other symptoms of unresectable gallbladder or bile duct cancer. During external radiation therapy, a machine directs radiation through the skin to the tumour and some of the tissue around it.

You may receive ERT on its own or with chemotherapy (called chemoradiation).

Find out more about radiation therapy and side effects of radiation therapy.

Targeted therapy uses drugs to target specific molecules (such as proteins) on or inside cancer cells. By targeting these molecules, the drugs stop the growth and spread of cancer cells while limiting harm to normal cells. You may have targeted therapy for unresectable bile duct cancer if it has certain genetic mutations.

Pemigatinib (Pemazyne) can be used for unresectable cholangiocarcinoma that has a fibroblast growth factor receptor 2 (FGFR2) mutation. This drug is usually given by mouth for 2 weeks followed by a 1 week break, before repeating the cycle. To determine if you can have pemigatinib, you need to have genetic testing to see if you have an FGFR2 mutation. Genetic testing is not available at all cancer centres in Canada.

Pemigatinib may not be covered by all provincial or territorial drug plans. Your doctor or healthcare team will discuss access to these drugs with you if you may benefit from this treatment.

Find out more about targeted therapy.

Immunotherapy helps to strengthen or restore the immune system's ability to fight cancer. This works to kill cancer cells and stop cancer cells from growing and spreading. You may have immunotherapy for unresectable or metastatic gallbladder or bile duct cancer.

Durvalumab (Imfinzi) is an immune checkpoint inhibitor that targets the PD-L1 checkpoint protein. It is given through a needle into a vein (intravenously), once every 2 to 4 weeks. You may have durvalumab on its own or with the chemotherapy drug gemcitabine.

Pembrolizumab (Keytruda) is an immune checkpoint inhibitor that targets the PD-1 checkpoint protein. It is given intravenously, once every 3 to 6 weeks. You will usually have pembrolizumab with gemcitabine.

Pembrolizumab may not be covered by all provincial or territorial drug plans. Your doctor or healthcare team will discuss access to these drugs with you if you may benefit from this treatment.

Find out more about immunotherapy.

Talk to your doctor about clinical trials open to people with unresectable gallbladder or bile duct cancer in Canada. Clinical trials look at new ways to prevent, find and treat cancer. Find out more about clinical trials.