Questions to Ask About Gallbladder Cancer Treatment

Gallbladder cancer arrives in one of two ways. Which one applies to you shapes every question below.

The first way is by surprise. The gallbladder was taken out for stones. Then the pathologist found cancer in it. Say the cancer is still inside the mucosa, which is the innermost lining. That is stage T1. NCI reports that cancer found this way is curable in more than 80 percent of cases.

The second way is with symptoms. Someone turns yellow, or has pain. A scan finds a mass before any surgery. NCI reports that cancer spotted this way has usually already grown through the muscle layer. It has often reached the serosa, the outer coat. That version is curable in less than 5 percent of cases.

One more fact helps put a gallstone history in proportion. Gallstones are found alongside most gallbladder cancers. But fewer than 1 percent of people with gallstones ever get this cancer.

Ask for the T stage. Then ask for the letter after it. The system is the AJCC TNM system, eighth edition. The differences are small. They change the operation:

• T1a: tumor invades the lamina propria, the thin layer just under the lining.
• T1b: tumor invades the muscular layer.
• T2a: tumor reaches the connective tissue outside the muscle, on the belly-lining side. It has not reached the serosa.
• T2b: tumor reaches that same tissue on the liver side. It has not gone into the liver.
• T3: tumor breaks through the serosa. Or it grows into the liver, or into one other nearby organ. That could be the stomach, duodenum, colon, pancreas, omentum or bile ducts.
• T4: tumor grows into the main portal vein or the hepatic artery. Or it reaches two or more organs outside the liver.

Node status has its own cut points. N1 means one to three nearby lymph nodes are involved. N2 means four or more. M1 means the cancer has spread far.

Ask which of these your report says, and ask to see the sentence itself rather than a summary.

Most people whose cancer was found by surprise face this decision. The honest answer is that it turns on the T stage.

For T1a disease, most cases are cured by the gallbladder removal alone. For T1b, NCI calls a second, bigger operation controversial. A multi-center review looked at people who did go back for more surgery. It found lymph node spread in 12 percent of them. No trial has compared the two paths head to head.

For T2 and T3 the numbers are sharper. One review followed people who went back to the operating room after a surprise diagnosis. Cancer was still there in 57 percent of T2 cases. Of those, 31 percent had it in lymph nodes and 10 percent in the liver. For T3 cases, cancer was still there in 77 percent. Of those, 46 percent had it in nodes and 36 percent in the liver.

On that basis, NCI says eligible patients may go back for more surgery. The targets are liver tissue near the gallbladder bed, the portal lymph nodes, and lymph tissue in the hepatoduodenal ligament. Looking back at past cases, wider re-resection can delay a return of the cancer. It may also improve survival.

Questions to bring:

• What is my exact T stage, and does my surgeon consider a second operation indicated at that stage?
• What would the second operation remove: how much liver, which lymph nodes, and would the bile duct come out?
• What are the surgical risks for me specifically, given my liver function and other conditions?

Say the gallbladder came out by keyhole surgery before anyone knew there was cancer. One specific risk applies. Cancer cells can settle at the small cuts where the instruments and camera went in. NCI notes this can happen. It also notes that all port sites are usually cut out in full, even for stage I cancers.

Ask whether your port sites were removed, or are planned to be. Also ask whether the operative note recorded any spill of bile or stones.

NCI cites a study of lymph node spread. In it, the standard operation had four parts. The gallbladder came out. A wedge of liver came out. The bile duct outside the liver came out. And the N1 and N2 lymph nodes came out.

The survival figures from that series show what node status does. Take tumors staged T2 through T4 with no nodes involved. The 5-year survival estimate was 42.5 percent. For the same tumors with nodes involved, it was 31 percent.

Surgery for cure is no longer possible once the cancer spreads past the nearby lymph nodes. The same is true once it reaches distant organs.

If you are yellow, that usually comes first. NCI says to consider draining the bile duct before surgery at stage III or IV. The method is a drain placed through the skin into the liver. Draining lowers bilirubin, so the liver can handle what comes next.

Ask whether your bilirubin is currently a barrier, what number it needs to reach, and how long drainage usually takes to work.

External-beam radiation has been tried, with and without chemotherapy. It has produced short-term control in small groups. It has also been given after surgery.

NCI is blunt about the evidence. There are no phase III studies backing radiation after surgery here. That holds even for high-risk local disease. If radiation is proposed, ask what it is meant to achieve. Ask too whether a trial would be a better route.

This cancer is uncommon. The operation is a liver operation. Two questions are fair and specific:

• How many gallbladder and bile duct cancer resections does this surgeon and this hospital do each year?
• Will my case be presented at a multidisciplinary tumor board, and can I see what was recommended?

A second opinion at a busy liver and bile duct center is worth asking about. That is most true before a second operation. Our page on getting a second opinion covers how to request records, and how long it takes.

Say the cancer turns out not to be removable. The questions then change a lot. Our page on metastatic gallbladder cancer covers chemotherapy, immunotherapy and biomarker testing. For the disease overall, start with gallbladder cancer.

• NCI PDQ on gallbladder cancer, for doctors
• NCI PDQ on gallbladder cancer, for patients