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Case history

image A 79-year-old widower, living independently in a ground-floor flat, was suffering from osteoarthritis of the knees and hips that limited his mobility. He had one daughter, who lived abroad. On a recent visit to the UK she was concerned that he had become fatigued, developed pruritus and lost significant weight. Investigations revealed obstructive jaundice due to a solid mass, closely associated with the pancreas and duodenum, with dilated intrahepatic bile ducts and appearance consistent with a T3N1M0 extrahepatic cholangiocarcinoma. The cancer was technically operable, but the patient was malnourished and his fitness precluded pancreatoduodenectomy.

The patient's jaundice was relieved by endoscopic retrograde cholangiopancreatography with stent insertion, and a biopsy confirmed adenocarcinoma. Following discharge, he attended outpatients with his daughter, where chemotherapy and best supportive care (BSC) treatment options were discussed. Initially, he accepted BSC, but a week later he requested a further consultation and asked to be considered for chemotherapy. The patient was assessed to have the capacity to make this decision and was offered cisplatin and gemcitabine. The oncologist was worried that the patient lived alone, and discussions included whether neighbours/friends could visit during treatment. The patient's daughter was able to arrange for a private carer to visit him at his home each morning.

Using oral nutritional supplements, the patient's condition improved to performance status (PS) 1, and he gained 2 kg over 4 weeks. A baseline CT scan was repeated and he received two cycles (repeated every 21 days) of full-dose cisplatin 25 mg/m2 (days 1 and 8), and dose-reduced gemcitabine 750 mg/m2 (days 1 and 8) because of concerns about the risk of neutropenia, with additional telephone support from the clinical nurse specialist. He then attended outpatients accompanied by his carer. He explained that he suffered significant fatigue that limited his normal activity. The carer mentioned that the patient questioned the value of chemotherapy but was worried that he may disappoint his daughter. A full blood count revealed significant myelosuppression.

The third cycle was put on hold and an early restaging CT was booked. Two weeks later, he attended outpatients with his daughter. The CT scan showed stable disease. The daughter encouraged her father to persevere with chemotherapy. The oncologist explained that her father's wishes were paramount. The patient explained that he felt much better prior to the chemotherapy. The oncologist revisited the rationale, potential benefits and drawbacks of chemotherapy. The patient asked for cessation of chemotherapy and was given BSC until his death 18 months later.

How should the patient be supported in the decision-making process?

How should the patient's condition be optimized ahead of potential chemotherapy?

What is the evidence behind the treatment options that the patient was offered?

What are the challenges of the Advanced Biliary Cancer (ABC)-02 trial combination chemotherapy regimen in older patients?

In the UK, approximately 2000 people are diagnosed each year with cholangiocarcinoma, and the typical age of presentation is the seventh decade of life. Cholangiocarcinomas ...

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