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TRENDS IN MANAGEMENT AND OUTCOMES OF HILAR CHOLANGIOCARCINOMA ACROSS A UNIVERSITY HOSPITAL HEALTHCARE NETWORK - A 15-YEAR EXPERIENCE
Aditya Gutta*, Lara Dakhoul, Mark A. Gromski, Attila Nakeeb, Michael G. House, Evan L. Fogel, James L. Watkins, Glen A. Lehman, Stuart Sherman, Jeffrey J. Easler
IU School of Medicine, Indianapolis, IN
INTRODUCTION: Multiple disciplines offer unique interventions for management of cholangiocarcinoma (CCA). Heterogeneity exists across centers for approach to CCA based on location of tumor, experience and expertise. Hilar cholangiocarcinoma (HCCA) adds further complexity to multidisciplinary decision-making due to variable presentation among individual patients and nuances of staging, hepatic drainage/resection and selecting among therapies. As novel diagnostic and therapeutic modalities have emerged, the management of HCCA has also evolved. Literature is lacking regarding trends for referrals, management and outcomes in large, networked healthcare systems that offer the entire range of therapies for HCCA.
AIM: Describe trends in referrals, management and outcomes in CCA and HCCA over the past 15-years within our academic health care system.
METHODS: We identified all patients with CCA that received care from 01/2001 to 12/2015 within the Indiana University Health Network (IUHN) tracked in the Indiana State Cancer Registry. Demographics, clinical data, initial stage and survival from diagnosis were collected from this prospectively maintained database. We reviewed medical records to clarify ambiguous/missing data and analyzed the results in 5 year eras.
RESULTS: A total of 352 patients (51% female, median age 67) with CCA (36% HCCA) were identified. Forty-two% of the patients (55% HCCA) were diagnosed at the academic health center (AHC). Despite an increasing volume of referrals, pre-diagnosis referrals to AHC decreased (p=0.031). For CCA, initial management strategies of hospice/palliative care (p=0.007), IR embolization (p=0.002) or resection (p=0.078) were increasingly deployed with each era. (Table 1) For HCCA an increase in initial referrals for palliative care/hospice (p=0.004) with fewer patients resected (p=0.027) was observed. MRI/MRCP (p=0.011) and ERCP (p=0.004) were increasingly utilized as diagnostic and/or palliative modalities. (Table 2) Despite these shifts in management strategies, no improvement in survival was observed for either groups.
CONCLUSION: In spite of clear shifts in management strategies and increased utilization of advanced diagnostic/therapeutic modalities (i.e. MRI/MRCP and ERCP), we observed little change in outcomes for CCA and HCCA over the past 15 years. An increasing proportion of patients referred to our centers are advanced stage and immediately transitioned to hospice. Novel strategies for early diagnosis, pre-referral screening and rapid consultation are needed to identify CCA patients at early stages and refer for potential curative therapy. Deployment of a dedicated, multi-disciplinary, system-wide CCA tumor board may have value in improving triage, access, management and outcomes.
Table 1: Clinical and tumor characteristics of all CCA patients
| | 2001 - 2005 | 2006-2010 | 2011-2015 | P | | ‡ No of patients (n=352) | 65 | 125 | 162 | - | | Median Age (years) | 66 | 68 | 67 | 0.207 | | Female, n (%) | 35 (53.8%) | 56 (44.8%) | 91 (56.2%) | 0.41 | | Type of CCA, n (%) | | | | 0.033 (overall) | | Intrahepatic | 32 (49.2%) | 52 (41.6%) | 87 (53.7%) | - | | Hilar | 18 (27.7%) | 51 (40.8%) | 58 (35.8%) | - | | Distal | 15 (23.1%) | 21 (16.8%) | 16 (9.9%) | - | | * Stage, n (%) | | | | 0.568 (overall) | | 1/2 | 21 (32.3%) | 54 (43.2%) | 51 (31.5%) | - | | 3 | 17 (26.2%) | 31 (24.8%) | 15 (9.3%) | - | | 4 | 23 (35.4%) | 38 (30.4%) | 72 (44.4%) | 0.072 | | Metastasis | 15 (23.1%) | 17 (13.6%) | 39 (22.1%) | 0.601 | | ^ Diagnosis at Academic Health Center (AHC) | 29 (44.6%) | 57 (45.6%) | 61 (37.7%) | 0.031 | | Diagnostics | | | | | | MRI/MRCP, n (%) | 10 (15.4%) | 37 (29.6%) | 74 (45.7%) | <0.0001 | | ERCP, n (%) | 28 (43.1%) | 67 (53.6%) | 84 (51.9%) | 0.257 | | Treatment modalities, n (%) | | | | | | Hospice | 5 (7.7%) | 13 (10.4%) | 32 (19.8%) | 0.007 | | Resection | 28 (43.1%) | 65 (52%) | 57 (35.2%) | 0.078 | | Exploratory Laparotomy | 9 (13.8%) | 6 (4.8%) | 14 (8.6%) | 0.443 | | Transplant | 3 (4.6%) | 3 (2.4%) | 2 (1.2%) | 0.129 | | Radiation | 18 (27.7%) | 14 (11.2%) | 24 (14.8%) | 0.131 | | IR Embolization | 0 (0%) | 5 (4%) | 16 (9.9%) | 0.002 | | Chemotherapy | 28 (43.1%) | 45 (36%) | 62 (38.3%) | 0.643 | | | | | | | | Survival (days) | | | | | | All patients | 700 | 610 | 471 | 0.06 | | Received treatment (n=262/74.4%) | 860 | 730 | 633 | 0.212 | | Resection (n=150/42.6%) | 990 | 884 | 806 | 0.646 |
‡ 86.1% with positive histopathology. - * Staging recorded at the point of contact with an IU Health Facility using the AJCC/UICC staging system - 7th edition.
- ^ Academic Health Center (AHC): Indiana Univeristy Hospital. Other IU facilities: Arnett, Frankfort, Methodist, Morgan, North, Springmill, Saxony and West.
Table 2: Clinical and tumor characteristics of patients with HCCA
| | 2001 - 2005 | 2006-2010 | 2011-2015 | P | | ‡ No of patients (n=127) | 18 | 51 | 58 | - | | Median Age (years) | 70 | 71 | 67 | 0.861 | | Female, n (%) | 10 (55.6%) | 21 (41.2%) | 31 (53.4%) | 0.714 | | | | | | | | * Stage, n (%) | | | | 0.091 (overall) | | 1/2 | 4 (22.2%) | 21 (41.2%) | 20 (34.5%) | - | | 3 | 6 (33.3%) | 15 (29.4%) | 9 (15.5%) | - | | 4 | 5 (27.8%) | 14 (27.5%) | 26 (44.8%) | 0.074 | | Metastasis | 1 (5.6%) | 7 (13.7%) | 13 (22.4%) | 0.306 | | | | | | | | ^ Diagnosis at Academic Health Center (AHC) | 8 (44.4%) | 32 (62.7%) | 30 (51.7%) | 0.991 | | | | | | | | Diagnostics | | | | | | MRI, n (%) | 3 (16.7%) | 21 (41.2%) | 30 (51.7%) | 0.011 | | ERCP, n (%) | 12 (66.7%) | 41 (80.4%) | 54 (93.1%) | 0.004 | | | | | | | | Treatment modalities, n (%) | | | | | | Hospice | 1 (5.6%) | 9 (17.6%) | 20 (34.5%) | 0.004 | | Resection | 9 (50%) | 22 (43.1%) | 15 (25.9%) | 0.027 | | Exploratory Laparotomy | 1 (5.6%) | 3 (5.9%) | 8 (13.8%) | 0.169 | | Transplant | 0 (0%) | 3 (5.9%) | 0 (0%) | 0.439 | | Radiation | 6 (33.3%) | 8 (15.7%) | 7 (12.1%) | 0.058 | | IR Embolization | 0 (0%) | 0 (0%) | 0 (0%) | - | | Chemotherapy | 8 (44.4%) | 14 (27.5%) | 18 (31%) | 0.486 | | | | | | | | Survival (days) | | | | | | All patients | 653 | 576 | 408 | 0.262 | | Received treatment (n=80/62.9%) | 794 | 623 | 676 | 0.687 | | Resection (n=46/36.2%) | 871 | 648 | 707 | 0.68 |
‡ 75.6% with positive histopathology. - * Staging recorded at the point of contact with an IU Health Facility using the AJCC/UICC staging system - 7th edition.
- ^ Academic Health Center: Indiana Univeristy Hospital. Other IU facilities: Arnett, Frankfort, Methodist, Morgan, North, Springmill, Saxony and West.
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