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Latest Advancements in The Treatment of Bile Duct Cancer

Melanie Cole (Host):  Highly experienced at diagnosing and treating bile duct cancer, City of Hope brings an aggressive multidisciplinary approach to caring for people with this disease, offering them and their loved ones the most positive outcomes possible. And through their clinical trials program, one of the most extensive in the nation, bile duct cancer patients can often access promising new anti-cancer drugs and technologies that are not available anywhere else. My guest today is Dr. Yuman Fong. He is one of today’s most respected and recognizable physicians in the treatment of liver, bile duct, gallbladder, and pancreatic cancer. He’s also the chair of the department of surgery at City of Hope. Welcome to the show, Dr. Fong. Thank you so much for being with us. Tell us a little bit about bile duct cancer. Is this a very common cancer? Is it a very scary cancer? 

Dr. Yuman Fong (Guest):  Melanie, thank you again for having me on the show. Bile duct cancer is actually a relatively rare cancer in this country. There are parts of the world where it’s actually very common, and I’ll go through why that’s so. But it is a very scary cancer simply because the diagnosis is usually associated with very complex treatment plans that have to be put together in order to allow the patient to survive their disease.  

Melanie:  What is the bile duct, Dr. Fong? 

Dr. Fong:  Well, the bile duct is just a pipe that carries bile around the liver and outside the liver into the intestines. The way the digestive system works is the liver makes bile that help digest food. This is the chemicals that are produced in the liver that comes down to digest our fats, our proteins, and many of the nutrients so that they can be absorbed by the intestines. And it’s made in the liver; it’s carried around the liver in a series of pipes called bile ducts. Then they’d all collect down to a very large bile duct, a large pipe that carries it directly into the small intestine right outside the stomach. Cancer can occur anywhere along these pipes. We segregate bile duct cancer into three parts. The ones that are inside the liver, those are called peripheral cholangiocarcinoma. That’s a fancy medical word for the tumors of the bile duct that happen inside the liver. Then there are the ones that occur right outside the liver. Those are called hilar cholangiocarcinoma—again, just fancy medical words for the tumor that happens right where the main bile duct comes out of the liver before it enters into the intestines. Because the bile duct passes through the pancreas before it enters the intestine, that’s the third type. The bile duct tumor that happens in the very bottom of the large bile duct before it enters into the intestines, those are oftentimes confused with pancreatic cancer, even though it behaves much better than a pancreatic cancer. Those are the three types of bile duct tumors and bile duct cancers that happen in men, and we segregate them anatomically because, again, the treatments of the three are very, very different. 

Melanie:  Why is it more rare in this country, you started to mention, and maybe more prevalent in other countries? 

Dr. Fong:  It’s because bile duct cancer is actually associated with three signs. One is hepatitis. Hepatitis B or hepatitis C virus, which are viruses that attack the liver, can actually cause the bile ducts inside the liver to form cancers. In parts of the world where hepatitis B and C are more common, the bile duct cancers are also more common inside the liver. Those parts of the world are China and Africa for hepatitis B. Those parts of the world are Italy—particularly Sicily—and Japan for hepatitis C. So it’s really the inflammation from the virus there that causes the cancers that form in the bile ducts inside the liver. For other types of bile duct cancers, they are associated with chronic inflammatory conditions, meaning diseases where the body actually causes an autoimmune reaction against its own tissues. Those are related to a kind of disease called sclerosing cholangitis, where for whatever reason, the body decides that the bile ducts are foreign to itself and starts attacking with its the immune system. You hear about that in very famous cases like -- remember Walter Payton, the football player? He actually formed one of these bile duct tumors inside his liver simply because his body was attacking his bile ducts. The third way in places where bile duct cancers are very common are chronic infections of some type. There is a worm in Southeast Asia that actually crawls up into the liver and causes inflammation. Those worms are called flukes. And it’s quite common in Northern Thailand, for example, and in those areas where people are chronically infected with this worm that they catch from raw fish. They end up having bile duct cancer, and therefore, in those regions, it’s much more common. 

Melanie:  What would someone experience? Because as you said, it might mask or be similar to pancreatic cancer, which is much more common in this country. And so what would you experience that would -- this isn’t something you obviously screen for, so why would someone even go see the doctor to get checked? 

Dr. Fong:  Well, we actually do screen for it. In fact, the screening for bile duct cancer is actually very straightforward. It is the annual physical. When somebody gets an annual physical and their liver enzymes, which are the blood test that tell us how our livers are working, are abnormal, one of the things that we look for is whether somebody has a bile duct cancer. The more common reasons that the liver enzymes are abnormal are either somebody has just had a few too many alcoholic drinks a few days before or that they have gallstones. If we don’t find that somebody is actually having troubles with gallstones or with a few too many drinks, then we start looking for bile duct cancer. Because when those liver enzymes are elevated, we worry about tumors like this. But the more common presentation for bile duct tumor is really somebody who presents with jaundice, or that they turn yellow. The reason this happens is because, again, the bile is actually made in the liver and meant to pass down these bile duct intubation tests and help digest food. When the bile duct is blocked in any way, then the bile backs up into the blood, then it deposits on the skin, and the skin takes on a yellowish hue because of the fact that bile is yellow. Then the urine turns very dark. The common presentation for a tumor like this is really that somebody suddenly turns yellow, the urine is really dark, and their stools are very light colored because bile no longer makes it down into the intestines, so pretty much the same presentation as someone who has pancreatic cancer. But when we go looking for the pancreatic cancer or gallstones and we don’t find gallstones and we don’t find a big lump in the pancreas, then we start suspecting bile duct cancer, because again, that would be the alternative in terms of what blocks the bile duct and causes jaundice. 

Melanie:  You explained everything so beautifully, Dr. Fong. Now, we only have a couple of minutes left. Tell us about some of the cutting-edge treatments you’re doing there at City of Hope. 

Dr. Fong:  Well, the most important treatment for bile duct cancer if possible is go remove it. For the ones that happen way down at the bottom of the bile duct, it is to go and do something called a Whipple Procedure. The medical term for this pancreaticoduodenectomy. It’s a big operation that removes that front part of the pancreas just as if it was a pancreatic cancer. What has been definitely shown is that kind of big operation is better done at places where a lot of it is being done. Around the country, it’s been very well accepted now that having such surgery at a major center decreases the risk of complications and even death from such operations. Again, over the last 20 years, we’ve gotten pretty good at taking those tumors out down there. If it’s inside the liver, or right outside the liver, in the main bile duct way up high, there are many operations that have now been perfected to go remove those, and some of those could even be done using a robot or using a laparoscope, operations where we can actually reach in with a small incision with multiple small instruments and take out cancer for someone without causing them a big recovery without making a huge incision. Many times, we catch these tumors after it’s already spread. That’s where the research comes in. Until about 10 years ago, our chemotherapy for this disease was terrible. Less than 10 percent of the people would even have any shrink to tumor based on chemotherapy. But over the last decades, because of work by pretty amazing chemotherapists and researchers, our chemotherapy has gone much, much better. Now we have good chemotherapy that we can give that has a fairly good chance of putting disease back into control and even some chance of sometimes shrinking the tumors enough so that the patients can become potential surgical candidates for removal and potential cure of the disease even after it’s spread. I think we’ve come a long ways over the last decade or in two decades. Our surgery is better. Our chemotherapy is better. Here is a disease that three decades ago would have been considered almost uniformly fatal that we are really making headways on. I’m just glad to be working at a place like City of Hope where we can actually use these therapies. 

Melanie:  Dr. Fong, thank you. You’ve given hope to so many and your information is so beautifully put. Thank you so much for being with us. You are listening to City of Hope Radio. For more information on bile duct cancer and Dr. Yuman Fong, you can go to cityofhope.org. That’s cityofhope.org. This is Melanie Cole. Thanks so much for listening.