During a recent visit to The University of Texas MD Anderson Cancer Center, dailyRx News had the privileged opportunity of sitting down and talking with specialists in cancers that aren’t so common.
We wanted to learn from people who focus on these rarer malignancies what patients ought to know.
A specialist in gallbladder cancer, Rachna T. Shroff, MD, assistant professor in the Department of Gastrointestinal Medical Oncology, spoke with us about the diagnosis and treatment of this uncommon cancer that affects about 7,000 Americans every year.
The gallbladder is part of the digestive system. It’s a small, pear-shaped organ that’s a bit remote, tucked within the folds of the liver. The gallbladder stores bile which is used to help break down food in the digestive process.
This organ is part of what’s called the biliary tract, and cancer can appear anywhere in this area.
We began our interview by discussing some of the basics.
dailyRx: What are the biliary tract cancers?
Dr. Shroff: The biliary tract cancers typically are gallbladder cancers and what’s called cholangiocarcinoma – cancers of the bile ducts.
These ducts can be inside the liver (intrahepatic), where the bile originates, or they can be ducts that are outside the liver (extrahepatic).
The characteristics, treatments and kinds of presentation of cholangiocarcinoma and gallbladder cancer can sometimes be similar, but these cancers behave differently.
dailyRx: Tell us about your patients.
Dr. Shroff: Most of my gallbladder cancer patients are women between the ages of 60 and 70.
Typically, our gallbladder cancer patients are of Latino origin, especially because we’re in Texas.
Native Americans are also at higher risk of this disease.
dailyRx: Why are Latinos and Native Americans more prone to gallbladder cancer, do you think?
Dr. Shroff: It’s thought to be related more to diet and environmental factors. The biggest risk factor for the development of gallbladder cancer is chronic inflammation of the gallbladder from gallstones.
People who develop gallstones are typically people with a fried, fatty type of diet. They are also often overweight.
We have yet to determine why millions of people in this country have gallstones and why there are only 7,000 cases of gallbladder cancers per year.
dailyRx: Are you seeing any changes in your patients?
Dr. Shroff: Unfortunately, we are also seeing people who are younger. We have a handful of patients who for whatever reason have developed this at a much younger age.
dailyRx: Why do you think you are seeing gallbladder cancer in younger people?
Dr. Shroff: The only thing that I would say is that some of the known risk factors for this disease are just related to risk factors for developing gallstones.
The Western diet is probably going to slowly but surely start shifting the age range to a younger population, but I can’t say that we’re definitively seeing that yet.
For now, most of my younger patients have had something else that might have predisposed them to the development of gallbladder cancer earlier on.
dailyRx: What are the symptoms of gallbladder cancer, and how is it diagnosed?
Dr. Shroff: I always tell my patients that this is the great masquerader because it mimics a gallbladder attack so it’s often times found incidentally.
Patients present with right-upper quadrant pain, sometimes they have nausea and vomiting, they have tenderness on exam, and sometimes they have jaundice.
They are evaluated with ultrasound and the clinician sees what looks like an inflamed gallbladder.
The surgeon goes in, removes the gallbladder because they just think it’s inflamed from gallstones, and then the pathologist looks at it under the microscope and sees cancer, which is often a surprise to the surgeon as well as obviously the patient.
Close to 50 percent of the cases of gallbladder cancer are found incidentally with laparoscopic removal of the gallbladder.
dailyRx: What are the next steps?
Dr. Shroff: If the cancer is starting to push into the muscle layer of the gallbladder, additional surgery is recommended. These are staged as T2 and higher tumors.
These patients should be referred to a surgeon, who goes in and scoops out the gallbladder bed which sits tucked into the liver. Two segments of the liver that are right adjacent to the gallbladder bed are removed.
Next, they take out lymph nodes in the area, which lets us know if there are any lymph nodes involved.
We know that about 75 percent of these patients who have had laparoscopic surgery have residual cancer – in those lymph nodes, in the liver near where they performed the surgery, or in the gallbladder bed itself.
So it’s very important to have that second step. That’s a really important thing.
dailyRx: What happens after surgery?
Dr. Shroff: Because we see so many gallbladder patients here at MD Anderson, we realized that gallbladder cancer is a systemic disease. It likes to spread. It likes to spread to the lungs, liver, and the peritoneum - or the abdominal cavity.
The highest risk for relapse, or for this cancer to come back, is actually more distant spread.
Depending on how advanced the cancer is, we will do chemotherapy, as well as perhaps chemoradiation, a procedure that uses chemotherapy agents to make the radiation more sensitive and effective.
dailyRx: What’s happening in the research world regarding gallbladder cancer?
Dr. Shroff: The big push is to understand the genetic profile of these diseases better.
There are certain parts of the world that have very high incidences of gallbladder cancer. Of the two highest incidences – one is in Chile and one is in northern India. We have a sister institution in Chile were we can examine more tissue for genetic changes that may become targets for new drugs that could be developed.
The other thing is developing a model we can use to study this cancer. We need to develop good animal models for gallbladder and biliary tract cancers so we can test drugs in those systems before we test them in humans.
In terms of treatment, similar to other cancers, the hot area is targeted therapy. There are a couple of specific targets that are proving to be interesting in gallbladder cancers.
Here at MD Anderson, we think that some of the difficulty might be from the fact that we’re grouping all of these cancers together, because cholangiocarcinoma and gallbladder cancer behave differently and they respond to chemo differently.
dailyRx: What would you like our visitors to know about gallbladder cancer?
Dr. Shroff: One of the things that’s important for them to know is that there is research going on in the field, and there are experts across the country who focus and emphasize their time on treating and pushing that research forward.
I think that it’s important for them to go to a center that has experience with these types of cancers. It might not be common knowledge what the correct treatment steps are.
So going to a place that has good multidisciplinary care is very important.
We'd like to thank Dr. Shroff for taking time to visit with us and share her expertise on these unusual cancers.