First-line therapy

First-line therapy refers to the first treatment used after diagnosis.

Surgery
Currently, surgerical removal of the CC tumor is the only curative treatment available for cholangiocarcinoma. Since CC is often caught late, surgery is often not possible. Sometimes surgery becomes possible after other treatments. Why do I include surgery in a discussion of first-line therapy options? Mainly because you really want to figure out how surgery fits into your potential treatment plan before settling on a first-line therapy. An important sequence of questions to ask your doctor:
 * Am I a candidate for surgery right now?
 * Could my first-line therapy lead to surgery in the future?
 * Does my first line therapy prevent or make a future resection more difficult?

Chemotherapy
Assuming surgery is not possible initially, the most common first-line therapy is a combination chemotherapy regime made up of two chemo agents:  Gemcitabine + Cisplatin (GemCis). This emerging standard of care is based on the results of the ABC02 clinical trial that demostrated the survival advantage of GemCis compared to gemcitabine alone.

Because Cisplatin can be difficult on the kidneys, sometimes oxaliplatin (a different platin that is less kidney toxic) is used instead as a first-line therapy. (Gemox).

Folfirinox is another chemotherapy combination that evidence suggests has survival benefits relative to gemcitabine alone (similar to GemCis). However, this evidence is not specifically for CC. Moreover, Folfirinox is often more toxic than GemCis, and as such is frequently used as a second-line instead of a first-line therapy.

Getting a chemo port
If chemotherapy is your first-line therapy, you will likely have an option to get a chemo port to facilitate infusions. Getting a port installed is a surgical procedure. Getting one can be scary, but the general consensus on the Cholangiocarcinoma forums seems to be that you will likely be happy that you had a port installed. Using IVs to draw blood and receive infusions can be very painful.

My wife had a port installed a couple of days after her diagnosis. It was a bit more painful than she was led to believe (it is surgery after all!), but was manageable. It was definitely worthwhile given how much easier it makes the infusion process.

Sample quote from the forums :

"Having a port makes it so much easier and faster.  I ended up having a port placed after my 3rd round of chemo.  It was such a blessing."

Other first-line therapies
jscott457 comment:

In my wife's case, the general plan was to use the standard first-line therapy of GemCis followed by radioembolization. The plan had to be changed because the GemCis had been pretty successful in attacking the cancer. After 6 months of GemCis, a PT scan indicated that my wife's intrahepatic CC tumors were not absorbing blood any faster than the background liver cells. While this was fantastic news, it meant that radioembolization was no longer the right approach (radioembolization relies on tumor blood uptake being much higher than surrounding tissue blood uptake). After going through this experience, I wonder if radioembolization first would have been a better strategy? If you start with active tumors, you can always go radioembolization and then chemo, but as we found out, you may not be able to go chemo then radioembolization. I asked the interventional radiologist if he thought we should have done radioembo first. He commented that radioembolization was not currently thought of as a first line therapy, but he would not be surprised if it become the first-line approach over the next 5-10 years. There is currently an ongoing clinical trial (NCT01253148) looking at this possibility. Hopefully results will be available in May, 2014.

