3 BTC testing and treatment challenges you can address to improve patient outcomes

Despite being rare, oncologists treating cholangiocarcinoma know that it presents outsized challenges—from late diagnoses to limited treatment windows and poor outcomes.^[] Clinicians constantly hit roadblocks—but emerging tools and strategies may offer a clearer path forward.

In an interview with MDLinx, Shubham Pant, MD, professor in department of gastrointestinal medical oncology, Division of Cancer Medicine at The University of Texas MD Anderson Cancer Center, shares his recommendations and potential solutions to combat three common challenges in improving BTC patient outcomes.

Inadequate tissue samples

Although there have been improvements in diagnostic techniques, most modalities — labs, imaging, brush cytology, fine needle aspiration, or image-guided biopsy—are not sensitive enough to effectively rule out a cholangiocarcinoma diagnosis. Thus when suspected, surgery may be indicated even without tissue confirmation.

“I think one of the big things in BTC is just the tissue," says Shubham Pant, MD, professor in department of gastrointestinal medical oncology, Division of Cancer Medicine, The University of Texas MD Anderson Cancer Center, in an interview with MDLinx. "You don't get enough tissues. Folks don't get enough tissue and send the sample for NGS [next-generation sequencing] and the [result] is ‘inadequate tissue’ or ‘quality not sufficient.’”

“I would encourage everybody to keep at it," says Dr. Pant. "If a new lesion comes up, biopsy that and send it. If you can't find a tumor, you should try to send circulating tumor DNA. I would be aggressive when looking. Make multiple attempts at sequencing if the first sample doesn’t [deliver]. At least you’ve looked under every rock before you say you can’t get a tissue sample,” he added.

Health inequities

Although the United States has a comprehensive medical system, socioeconomic barriers may raise the cancer burden during the early diagnosis stage. Delayed diagnosis is tied to disparities in income in more advanced cancers.

Studies have shown that people with a higher-level of socioeconomic status are more likely to take part in screening and have higher quality treatment throughout disease progression. On the other hand, individuals with a lower level of socioeconomic status, are expected to exhibit worse cancer survival rates and to have an increased risk of death due to obstacles to obtaining treatment before the cancer has become incurable.^[]

The American Cancer Society points to other factors including racism, inadequate health insurance coverage, and lack of transportation, housing and affordable nutrition as barriers to a person's ability to prevent, diagnose, treat, and survive cancer.

The National Comprehensive Cancer Network (NCCN) workgroup on Measuring and Addressing Health-Related Social Needs in Cancer advises transportation access, housing security, access to food, and financial security as means that should be assessed for all patients requiring for cancer care. The NCCN also stresses that following screening, healthcare institutions must address patients’ identified unmet needs. ^[]

“Some smaller rural areas and community practices may find it challenging to access diagnostic testing, but I think we just need to make it more broadly available and not have any insurance challenges to getting these test approvals in resource-limited settings,” says Dr. Pant.

Provider awareness

A final challenge involves clinician exposure and knowledge of BTC.

“Community oncologists do a fantastic job," says Dr. Pant. "They are treating all tumors, but, there are hundreds of FDA approvals a year in oncology. How do you keep up with all this data? Especially with cholangiocarcinoma, where you see one case a year."

"Continuing education is critical to our mission and for the patients,” he adds stressing that articles such as this can help ensure clinicians stay updated.