Advanced gallbladder cancer

Advanced gallbladder cancer means the cancer is either locally advanced (stage 3) or has spread to other parts of the body (metastatic or stage 4).

Unfortunately, most people with gallbladder cancer have advanced cancer when they are diagnosed. This is because gallbladder cancer doesn’t usually cause symptoms early on. And when it does cause symptoms, they can be vague and difficult to spot.

Locally advanced gallbladder cancer 

Locally advanced gallbladder cancer is when the cancer has not spread to distant parts of the body. But it is spreading in and around the gallbladder. This means it may block or completely surround the nearby major blood vessels. Or it may grow into nearby organs such as the liver or small bowel (duodenum). 

Metastatic gallbladder cancer

Metastatic gallbladder cancer is when the cancer has spread to another part of the body, such as the lungs or bones. This may also be called advanced gallbladder cancer.

Treatment options for advanced gallbladder cancer

The main treatments include:

• surgery
• chemotherapy
• immunotherapy
• targeted cancer drugs
• radiotherapy
• treatment to control symptoms

It can be difficult to decide which treatment to have or whether to have treatment at all when you have advanced cancer.

Having treatment can affect your quality of life. It’s important to understand what the aim of treatment is and what the side effects are. It's also important to think about other factors such as the time that you’ll spend in hospital or travelling to the hospital.

Your doctor and specialist nurse will be able to talk this through with you and answer any questions you have. You might find it helpful to talk things over with a close relative or friend. Or there may be a counsellor at the hospital you can talk to.

Types of treatment

The treatment you have depends on:

• where your cancer has spread to
• the size and number of any secondary cancers
• your general health 
• any treatment you have already had
• your symptoms

Your doctor might suggest one or more of the following treatments.  ​​​​

Surgery for locally advanced gallbladder cancer

You might be able to have surgery if you have locally advanced gallbladder cancer. You might have chemotherapy first to try to reduce the size of the cancer and make an operation more successful. This is called neo adjuvant chemotherapy. This type of surgery is a major operation. Your surgeon makes sure you are well enough to have it.

Surgery to relieve symptoms or a blockage

If your gallbladder cancer is at an advanced stage where it can’t be cured, you might have surgery to relieve your symptoms. Surgery can give you a better quality of life for longer.

Sometimes the cancer can block bile from going from the gallbladder into the small bowel. This causes jaundice. To help the bile drain into the bowel again, your doctor might put a small tube into the small bowel. The tube is called a stent. Or they might do an operation to bypass the blockage.

Having a stent

A stent is a small tube that goes inside the bile duct or bowel to keep it open and stop jaundice.

Most stents are made of an expandable wire mesh. If they get blocked, it is often possible to unblock them or put in a new stent.

Stents can be put in:

• by endoscopy
• through the skin (percutaneously) - with a needle and guide wire

By endoscopy

If the cancer is near to your stomach or in the first part of your small bowel (the duodenum) your doctor might put the stent in endoscopically.

You have a sedative injection. The doctor then puts a long, flexible tube called an endoscope into your mouth and down your throat to your stomach. It passes through to the beginning of the small bowel (your duodenum) and the opening of your bile duct.

The doctor injects dye into the bile duct. X-ray then shows where the duct is blocked. The doctor can stretch the bile duct open and put the stent in place.

Through the skin 

You’ll have a sedative and a local anaesthetic to numb the area where the needle is to be put in.

Before the procedure begins, the radiologist takes an x-ray of your abdominal area with an overhead camera. This comes up on a screen that the doctor can watch while they do the procedure.

The doctor pushes a needle attached to a guide wire between two of your ribs on your right side. Your doctor can carefully guides the needle into position by watching the screen.

The doctor injects the dye so it shows up on x-ray and shows up the blockages in your bile duct system. Once the needle is in exactly the right place, the doctor feeds the stent along the guide wire and takes the needle out. The whole procedure usually takes about an hour.

Side effects after a stent

Sore skin
You might have sore skin if the stent was inserted through the skin. This should only last a few days.

Bleeding
The liver has a very rich blood supply and sometimes bleeds a little after this procedure. Contact your doctor straight away if you have pain, swelling or bruising over the liver area.

Blood in your poo
Some people have blood in their poo. In a small number of people this is a sign of a leaking blood vessel in the liver. Let your doctor know if you have blood in your poo. You might need further treatment to stop the bleeding and a blood transfusion to replace lost blood.

Infection
You might have antibiotics for a few days after your stent to try to prevent infection. While you have a stent you are at risk of infection. Bacteria from the gut can travel up the stent to the gallbladder. 

Contact your doctor straight away if you have signs of infection (high temperature and shivering). You may need to go into hospital for antibiotic treatment.

Sometimes stents can become blocked after a few months and you might notice jaundice again. If this happens, you can have the stent unblocked or replaced.

Bypass surgery

A bypass means that the surgeon will cut your bile duct above the blockage and reconnect it to your small bowel (intestine). This allows the bile to go around (bypass) the cancer. It is quite a major operation, so it is rare to have this type of surgery for advanced cancer.  

If you are considering whether to have this type of major surgery, you may want to talk it over with your close family and friends. You can also talk to your doctor and nurses.

Chemotherapy

Chemotherapy uses anti cancer (cytotoxic) drugs to destroy cancer cells. If you have advanced gallbladder cancer, your doctor might suggest chemotherapy to shrink the cancer, slow its growth or relieve symptoms.

The most common type of chemotherapy for advanced gallbladder cancer is a combination of gemcitabine and cisplatin.

If you can't have cisplatin, you might be offered oxaliplatin. Or you might have either gemcitabine, fluorouracil (5-FU) or capecitabine on their own.

Chemotherapy might also be given in combination with a targeted drug or immunotherapy.

Targeted cancer drugs and immunotherapy

Targeted cancer drugs work by targeting the differences in cancer cells that help them to grow and survive. Other drugs help the immune system to attack the cancer. They are called immunotherapies.

You might have one of these treatments if your cancer has a gene change (mutation) or a certain protein that helps the cancer grow.

You might have the immunotherapy drug pembrolizumab in combination with gemcitabine and cisplatin.

You might be offered the immunotherapy drug durvalumab in combination with gemcitabine and cisplatin.

Targeted drugs and immunotherapy are also sometimes given as part of a clinical trial 

Radiotherapy

Radiotherapy uses high energy x-rays to treat cancer cells. You might have radiotherapy to control pain and relieve the symptoms of advanced gallbladder cancer. 

Pain control and other symptoms

You might experience pain if you have advanced gallbladder cancer. The pain may be in other parts of the body if the cancer has spread.

Cancer treatments such as chemotherapy and radiotherapy can help to control pain. They can shrink a tumour that is pressing on a nerve or another organ and causing pain. Painkillers can also help. Your doctor will tell you what painkillers to take. They can also refer you to the palliative care team. They can help with pain control and other symptoms. 

Coping with advanced gallbladder cancer

Finding out that you have advanced gallbladder cancer, or that your cancer has come back, can be devastating. You may feel shocked and confused, and find it difficult to take in anything that is being said to you. There is support available to help you cope with emotional, practical and physical issues when you have advanced cancer.