Dr. Milind Javle: Thank You, Lisa

Lisa Garvin: Welcome to Cancer Newsline, a podcast series from the University of Texas MD Anderson Cancer Center. Cancer Newsline helps to stay current with the news on cancer research, diagnosis, treatment, and prevention, providing the latest information on reducing your family's cancer risk. I'm your host, Lisa Garvin. Our guest today is Dr. Milind Javle. He's a professor of gastrointestinal medical oncology here at MD Anderson, and our subject today is a fairly rare cancer of the gallbladder. Welcome, Dr. Javle.

Dr. Milind Javle: Thank you, Lisa.

Lisa Garvin: Let's first of all start off. I think everyone knows they have the gallbladder, but they probably don't know where it is or what it does.

Dr. Milind Javle: So the gallbladder is at the lower portion of the liver, and basically is a little sac that stores bile. So the bile flows from the liver into this little sac, and it stays there until we eat, and every time we eat, it pushes a little bit of bile into the stomach, into the small intestine, so that the food that we eat gets digested. If you think about eating fat, it's not going to float. It's not going to get easily digested, so the file ends up emulsifying that fat and makes it easily digestible.

Lisa Garvin: So as far as cancers of the liver go and parts associated with the liver, is gallbladder it pretty rare type of cancer?

Dr. Milind Javle: That's right. Often it's confused with liver cancer, and it's, in fact, different, because the liver cancer refers to cancers arising from the liver cells, and that's a cancer scene with hepatitis, alcoholism, cirrhosis, but the liver also has this extensive channel of bile ducts, which carry the bile to the intestine, and this is called biliary tract cancer, and an important component of the biliary tract cancer is the gallbladder. So the gallbladder cancer is relatively rare. You're right. It's about 5,000 cases in the US every year.

Lisa Garvin: Is it more prevalent among certain demographics?

Dr. Milind Javle: Yes, you know, it is interesting. There is a strong predisposition for certain ethnic groups. For instance, in the United States, it's the Hispanic community, Native Americans, native Alaskans, they are more likely to develop this cancer. So all over the world, gallbladder cancer appears to be declining because increasing use of cholecystectomy. That is, removal of the gallbladder for gallstones, and this procedure itself may prevent development of cancer, but there are certain ethnic groups and certain age groups where, actually, the cancer is on an upswing. So, for instance, in the United States, in the southern part of the United States, because of our changing demographics, there is a younger population, particularly among the Latin American community, where the incidence of gallbladder is actually increasing. Lisa Garvin: Is that an environmental factor or a familial factor?

Dr. Milind Javle: So, it's not a familial factor, Lisa, but it is certainly genetic and environmental. So by genetic I mean that there are certain ethnic groups that are predisposed to it for reasons we do not know, but we know, for instance, that the Hispanic community, Native Americans, for instance, have a much higher incidence of gallstones than their, say, Caucasian counterparts, and this seems to be a very big risk factor in this cancer development. The other environmental factors that are linked to this cancer, the main one is obesity and gender. So often, this cancer is more likely to be seen in women, and women who have a higher body mass index and have a history of gallstones.

Lisa Garvin: Now, when the typical person has gallstones, they're not taking the gallbladder out at the first incident. Are they trying to preserve the gallbladder when people have gallstones?

Dr. Milind Javle: Well, if you think about it, it is estimated that anywhere between 10% to 20% of the adult population of the United States have gallstones, so that's really a huge number. Whereas gallbladder cancer is only seen in 5,000 patients. So it's not practical to have gallbladders removed, especially if the patient doesn't have any symptoms from the gallstones, which is the most common clinical manifestation. So I would say that we still have to identify certain groups, and they are subgroups that are at risk for developing the cancer, and they include those who have large stones, stones that are painful, especially if they come from the at-risk community, such as the Hispanic community or the Native Americans. Those are patients who probably should have their gallbladders removed to prevent the risk of cancer.

Lisa Garvin: So when were talking about, I think we've covered most of the risk factors. You know, as far as, you know, the demographic issue and everything else. Are there any other risk factors?

Dr. Milind Javle: So I have to mention that, you know, I mentioned the risk factors that with see in the United States, but there are about 100,000 gallbladder cancer cases that occur throughout the world, and certainly, for instance, in Houston, we are such a composite of different communities, but we do see patients from all over the world. So, for instance, in South America, particularly in Chili at the tip of South America, it's the second most common cancer that you see in women, after cancer of the cervix. Similarly, in South Asia, in India, where I'm originally from, in the northern part of India, it is a very important cancer in women, for instance, in the New Delhi area. We do not know why the certain subgroups are affected, but we do see some of these patients, certainly, in the US who have now developed the cancer, so there are ethnicities and subgroups besides the ones who I mentioned, who are also at a high risk for developing the cancer, and indeed, in those sub groups, the cancer is not on a decline. Internationally, there are certain pockets in the world where the risk is still pretty high.

Lisa Garvin: When gallbladder is diagnosed, is it ever diagnosed early and is it often misdiagnosed as liver cancer?

Dr. Milind Javle: It is diagnosed early and, unfortunately, is very commonly misdiagnosed. So, for instance, in the US, the most common presentation is an incidental finding during the gallbladder removal for gallstones. So there are certain important criteria for gallstones and certain criteria for gallbladder cancer. Just because this cancer's so rare, often as criteria for cancer is not appreciated in advance, and patients end up getting laparoscopic gallbladder resection, or laparoscopic cholecystectomy, which ends up being, actually, not only inadequate, but sometimes a harmful operation for the patient.

Lisa Garvin: Does it spread the cancer cells?

Dr. Milind Javle: Yes. If this operation is done for gallbladder cancer that is not localized but it's somewhat locally advanced, then the actual procedure may help to seed the rest of the abdominal cavity or lead to it's spread. So it's important that, you know, when the surgeon identifies either preoperative or intraoperatively that this may be gallbladder cancer, they need to stop and then refer the patient to a tertiary cancer hospital. So, for instance, yesterday my clinic, I saw an infectious disease specialist from another state who went in for gallbladder surgery ostensibly for gallstones, but his surgeon felt this looked a little beyond gallstones cholecystitis, and basically, closed up and sent them here for a surgical procedure, and that was the best thing they could have done, because had this man got an inadequate and unnecessary procedure, it could actually expedite his downfall.

Lisa Garvin: So what is the approach here at M.D. Anderson?

Dr. Milind Javle: So the approach at MD Anderson is if the patient is diagnosed de novo. That is, there is no prior surgical resection, but we see it on radiology, then we have a multidisciplinary approach. Our surgeons take a look at the patient and see if this patient can be cured with a surgical resection. If they feel that it is a borderline situation, then they refer this patient to someone like me or my group, medical oncologists, so that we can give chemotherapy beforehand, downstage the cancer, and then resect it subsequently. If the patient has undergone surgical resection and then comes to M.D. Anderson, then we first the adequacy of the surgery. So the surgeons then evaluate if we need to re- resect and clear out the margins or clear out areas that this cancer may have possibly spread to, and then following that, we give them radiation and chemotherapy to prevent any progression or recurrence.

Lisa Garvin: Now can you use laparoscopy or robotics for this. It sounds like you still have to do a standard incision.

Dr. Milind Javle: That's right. We can do robotics or laparoscopically for the very early gallbladder cancers, but typically, those cancers are really not diagnosed, because patients don't have any symptoms. Unless they're discovered for some incidental finding during a radiological examination, but most of the time, you need an open laparotomy.

Lisa Garvin: And as far as the prognosis for people who, you know, you gotten the cancer. You have, you know, positive margins, what is their outlook?

Dr. Milind Javle: So, the outlook, unfortunately, is pretty bad. If this cancer is diagnosed, like you mentioned, at a positive margin or it's unresectable, then often survival extends to just about a year.

Lisa Garvin: And what is the overall prognosis for just kind of the basic prognosis for people with this disease?

Dr. Milind Javle: So the overall prognosis, if you look at patients who got resected and had a complete resection and include, among them, those who had inadequate resection, then the overall five-year survival tends to be about 50%. Lisa Garvin: And it sounds like, as you were mentioning before, that it's wise once this is discovered to step back and go to an expert place for treatment.

Dr. Milind Javle: Absolutely. If this is suspected or diagnosed, certainly, then this is a rare cancer for which expertise is limited, and surgical skills are available only at a few tertiary centers. So it's important then to take a step back and let the patient have the benefit of multidisciplinary approach.

Lisa Garvin: Great, thank you very much.

Dr. Milind Javle: Thank you, Lisa.

Lisa Garvin: If you have questions about anything you've heard today on Cancer Newsline, contact Ask MD Anderson at 1-877-MDA-6789, or online at mdanderson.org/ask. Thank you for listening to this episode of Cancer Newsline. Tune in for the next podcast in our series.