This is the fifth part of our series about the condition based on our patient booklet “Fast Facts for Patient and Supporters: Cholangiocarcinoma”. This article focuses on the treatment of cholangiocarcinoma by systemic therapy and infusion therapy.

Systemic Therapy

Systemic therapy is treatment that goes throughout the whole body. There are three different types of systemic therapy: chemotherapy or cytotoxic therapy, immunotherapy and targeted therapy.

The reasons you may need systemic therapy can include one or more of the following:

• There are tumors in different parts of the liver.
• The position or nature of the cancer means localized treatment is unlikely to be effective.
• The lymph nodes are affected.
• There is evidence that the cancer has spread to another part of the body.
• The tumor is too big to be removed and needs to decrease in size to allow for surgical removal.
• The tumor has been removed but microscopic cancer cells may be still present and need to be destroyed.
• Radiation therapy requires a boost to increase the chances of killing the cancer cells.

Systemic therapy can be used as neoadjuvant or adjuvant treatment or as palliative treatment. It typically involves delivering therapy by vein or tablet and targets all areas where cancer exists.

Neoadjuvant or adjuvant therapy is given to people whose disease is located in one area of the liver or bile duct, without evidence of spread to other areas of the body. This aims to decrease the size of the tumor (neoadjuvant therapy) and prevent the growth of microscopic cancer cells that may remain after removal of the primary tumor (neoadjuvant and adjuvant therapy).

Palliative therapy aims to control the growth of the cancer to help with quality and length of life. It is given to people whose disease has spread to more than one area of the body (metastatic).

Chemotherapy or cytotoxic therapy uses medicines that aim to stop cancer cells from growing and dividing. They typically target cells that are dividing or making DNA copies, so cells like cancer cells, that are dividing rapidly, are more likely to be affected. Noncancer cells, like blood cells and cells lining the gastrointestinal tract, can also be affected, leading to side effects.

Immunotherapy stimulates or suppresses cells in the body’s immune system. These therapies aim to enable the immune system to fight the cancer, rather than directly attacking the cancer.

Targeted therapy identifies and attacks specific tumor cells that have changes in their DNA or proteins on their surface, which usually results in less harm to other cells. These drugs typically block the activity of proteins or other signals in the body that are involved in cancer growth and spread.

Systemic therapy can be given in many ways. Intravenous (IV) therapy is given directly into a vein, while oral therapy is typically a pill, capsule or liquid that you swallow by mouth. Sometimes, therapy can be injected as a shot in the skin or muscle. Different systemic therapies are given in different ways, and the schedule of treatment depends on the medication you are receiving and how it is delivered to you.

Knowledge Point

Adjuvant therapy is treatment given after a tumor has been taken out surgically and attempts to kill microscopic cells before they grow into established tumors.

You may be recommended to have adjuvant therapy after surgery to lower the risk of the cancer returning. This will depend on various characteristics, including the location of your tumor and your overall health.

In some cases, the tumor is too large to be taken out straight away or it may be close to blood vessels that cannot be removed. In this case, neoadjuvant therapy may be recommended. This is treatment given before the tumor is removed, with a goal of decreasing the size of the tumor to increase the chances of having the whole tumor removed at surgery.

Infusion Therapy

Many medications used to treat cholangiocarcinoma will be given by infusion. This can be done through a needle in the arm (peripheral intravenous, or IV, needle) or a port. Infusions can be given over a period of hours in the infusion center of your cancer center, or they can be delivered over the course of a few days via a portable infusion pump that you wear.

Before most infusions, you will undergo blood tests to check your blood counts, liver and kidney function and electrolytes to ensure that your body has enough reserve to tolerate the infusion and any potential side effects.

You may receive premedications that will help you to get through the infusion or prevent side effects from it. These can be medicines to control nausea, diarrhea, allergic reactions or swelling. Nurses trained specifically in cancer infusion therapy will monitor you for any side effects or reactions during the infusion. Tell your infusion nurse if you feel nauseated, have pain, have the urge to go to the bathroom or any other side effects.

If you receive your treatment through an IV needle, a new needle will be put in your arm at the start of each treatment and will be removed when the infusion is done.

With some treatments, your infusion will use a small pump that infuses medication over a period of days. This is typically delivered continuously through a port or large IV needle that is anchored in a larger vein. It is usually given as part of an outpatient treatment. After treatment, the pump is disconnected by someone trained to do this – this may be the infusion center nurse, a home visiting nurse or one of your caregivers who has received training.

Use of a Port

A port is a small, round metal or plastic disc that is placed under the skin on your chest or arm and connects to larger blood vessels in your body. Needles can be inserted through the skin into the port to draw blood and to deliver infusions. Ports can also be used to deliver treatments administered via infusion pumps.

Care of the Port

Usual care for a port involves getting it flushed by the infusion center nurses on a regular basis, as defined by your treatment team. Notify your oncology treatment team if your port becomes red or painful or if any fluid drains from it.

Please check out the other posts of our series here:

• What Is Cholangiocarcinoma, How Does It Develop and What Are Its Symptoms?
• Cholangiocarcinoma: Seeing Your Doctor & Who Is Who
• Cholangiocarcinoma: Diagnostic Tests, Procedures and Staging
• How Can Cholangiocarcinoma Be Treated by Surgery and Radiotherapy?

Information based on Fast Facts for Patients and their Supporters: Cholangiocarcinoma (Karger, 2021).