Diagnosis still late for cholangiocarcinoma, cases on the rise

It is a rare cancer of the biliary tract which, due to late diagnosis, is still particularly difficult to treat in the vast majority of patients. It is cholangiocarcinoma, a ‘silent’ neoplasm often characterized by generic symptoms such as abdominal pain, weight loss, nausea, a general sense of weakness and fatigue that can be easily underestimated or confused with those of other pathologies. It is a constantly growing disease: new cases in Italy have increased by 14% in 5 years, from 4,700 in 2015 to 5,400 in 2020. According to a multicentre study conducted in the United States, the forecast is that in about 10 years, together to pancreatic cancers, primary cancers of the liver and biliary tract will outnumber more common cancers such as colon and lung cancers. “Currently the incidence of cholangiocarcinoma in Italy ranges from 3 to 4 cases out of 100 thousand per year – explains Domenico Alvaro, dean of the Faculty of Medicine and Dentistry of the Sapienza University of Rome and coordinator of the ‘Cholangiocarcinoma Working Group’ which has developed new lines guide of the Higher Institute of Health on the disease – There is however a huge difference between the various countries in the world according to the variability of the incidence of risk factors, for example in Thailand the incidence is over 100 cases per 100 thousand inhabitants per year “. The progressive increase in incidence mainly concerns the intrahepatic form, while for the perilary form the incidence is more or less stable. The increase in incidence recorded in Italy is in the order of 4-5% per year, which means that in 15 years there will be almost a doubling of cases. “Given its poor prognosis, this progressive increase in incidence must worry us – warns Alvaro – It must commit all medicine to research predictive factors and identify patients at risk in order to carry out screening and surveillance, which is the most effective way to prevent and diagnose this type of cancer at an early stage “. To date, in fact, there are no methods for early diagnosis, because the disease is usually asymptomatic for a long time. Therefore, there are no screening tests or routine diagnostic tests able to identify it at an early stage, when surgical removal is still possible. More specific symptoms (jaundice for example) appear only in the advanced stage of neoplastic disease. “Unfortunately, the diagnosis in the vast majority of cases is late – underlines the specialist – so we get there when at least in 60% of cases the patients cannot be subjected to the only effective treatment which is surgery. This happens because this tumor shows signs only in the late stages, in the intrahepatic form only when it is so widespread in the liver that it begins to give symptoms such as abdominal pain, weight loss, nausea, malaise or jaundice “. This represents a big problem for medicine because, either it will be possible to identify the subjects at risk for surveillance, or preventive medicine will still fail for cholangiocarcinoma. The new guidelines just published by the ISS and shared by almost all the scientific societies related to the gastroenterological, oncological, radiological and surgical areas and patient associations, highlight the need for these patients to be managed by a multidisciplinary team which includes gastroenterologists, radiologists, oncologists and interventional radiologists, because they are extremely complex patients who require interaction between the various specialists. “The strength of these guidelines is to outline step by step the behavior suggested in daily clinical practice. The fact that patient associations also participated in the drafting – concludes Alvaro – gives them further strength and importance “.