Gallbladder CancerLast Updated: April 10, 2009 This section has been reviewed and approved by the Cancer.Net Editorial Board, 03/09 Overview
Gallbladder cancer occurs when normal cells in the gallbladder begin to change and grow uncontrollably, forming a mass called a tumor. A tumor can be benign (noncancerous) or malignant (cancerous, meaning it can spread to other parts of the body). Primary gallbladder cancer is cancer that starts in the gallbladder, as opposed to cancer that began somewhere else in the body and spread to the gallbladder. The gallbladder is a pear-shaped organ located just under the liver. The gallbladder stores bile, a fluid made by the liver that helps to digest fats. Bile is released from the gallbladder through a tube, called the common bile duct, as food is broken down in the stomach and intestines. The gallbladder’s wall is made up of three main layers of tissue: the mucosa, which is the innermost layer and covers the wall of the gallbladder; the muscularis, the middle layer of smooth muscle; and the serosa, the outer layer. Primary gallbladder cancer begins in the inner layer and spreads into the outer layers as it grows. Statistics In 2009, an estimated 9,760 adults (4,320 men and 5,440 women) in the United States will be diagnosed with gallbladder and other biliary cancers. It is estimated that 3,370 deaths (1,250 men and 2,120 women) from these diseases will occur this year. Cancer statistics should be interpreted with caution. These estimates are based on data from thousands of cases of this type of cancer in the United States each year, but the actual risk for a particular individual may differ. It is not possible to tell a person how long he or she will live with gallbladder cancer. Statistics adapted from the American Cancer Society's publication, Cancer Facts & Figures 2009. Find out more about basic cancer terms used in this section.Risk Factors
A risk factor is anything that increases a person’s chance of developing cancer. Some risk factors can be controlled, such as smoking, and some cannot be controlled, such as age and family history. Although risk factors can influence the development of cancer, most do not directly cause cancer. Some people with several risk factors never develop cancer, while others with no known risk factors do. However, knowing your risk factors and communicating them to your doctor may help you make more informed lifestyle and health-care choices. The following factors can raise a person's risk of developing gallbladder cancer: Gallstones. Gallstones, the most common risk factor for gallbladder cancer, are a rock-like formation of cholesterol and bile salts that can occur in the gallbladder or bile duct. Gallstones are the most common digestive disease in the United States, and between 75% and 90% of people with gallbladder cancer have a history of gallstones. However, only a small proportion of people with gallstones develop gallbladder cancer. Gallbladder polyps. This type of polyp is a growth that sometimes forms when small gallstones get embedded in the gallbladder wall. Gallbladder polyps bulge inward from the inner gallbladder wall. Some polyps may also be caused by inflammation. Doctors often recommend gallbladder removal for people who have polyps larger than one centimeter because these are more likely to be cancerous. Age. Most people diagnosed with gallbladder cancer are older than 70. Gender. Women are about twice as likely to develop gallbladder cancer as men. Ethnicity. Mexican Americans and Native Americans, particularly in the southwestern United States, are more likely to develop gallbladder cancer than the general population. Smoking. Tobacco use may increase the risk of gallbladder cancer. Family history. A family history of gallbladder cancer slightly increases a person’s risk of developing gallbladder cancer. Symptoms
People with gallbladder cancer may experience the following symptoms. Sometimes, people with gallbladder cancer do not show any of these symptoms. Or, these symptoms may be caused by a medical condition that is not cancer. If you are concerned about a symptom on this list, please talk with your doctor. Gallbladder cancer is usually not found at an early stage because the gallbladder is located deep inside the body. Therefore, gallbladder cancer can be difficult to detect during routine physical examinations. Sometimes, gallbladder cancers are found unexpectedly after removal of the gallbladder for other reasons, such as gallstones. When symptoms do occur, they include:
It is important to remember that these symptoms can also be caused by many other illnesses, such as a stomach virus. It is recommended that people with any of the symptoms listed above talk with their doctor. Diagnosis
Doctors use many tests to diagnose cancer and determine if it has metastasized (spread). Some tests may also determine which treatments may be the most effective. For most types of cancer, a biopsy is the only way to make a definitive diagnosis of cancer. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis. Imaging tests may be used to find out whether the cancer has metastasized (spread). Your doctor may consider these factors when choosing a diagnostic test:
In addition to a physical examination, the following tests may be used to diagnose gallbladder cancer: Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. The sample removed from the biopsy is analyzed by a pathologist (a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease). The sample of tissue can be taken one of several ways: during a surgery; by using a minimally invasive surgical technique known as laparoscopy; or by fine needle or thick needle aspiration (a core biopsy), using a computed tomography (CT or CAT) scan or ultrasound to guide the needle placement. In some cases, a biopsy is done by passing an endoscope (a thin, lighted, flexible tube) through the mouth, past the stomach, and into the first part of the intestine. A tool can be passed from the endoscope through the intestinal wall to remove a sample of tissue. Endoscopic retrograde cholangiopancreatography (ERCP). This test allows the doctor to see inside the body. The person is lightly sedated, and the doctor inserts an endoscope through the mouth, down the esophagus, and into the stomach and small bowel. A smaller tube or catheter is passed through the endoscope and into the bile ducts. Dye is injected into the ducts, and the doctor takes x-rays that can show whether a tumor is present in the area around the bile ducts. Sometimes, the procedure can be helpful to detect a tumor starting in the gallbladder. A plastic or metal stent can be placed across an obstructed bile duct during ERCP to help relieve jaundice if it is present. An experienced gastroenterologist (a doctor who specializes in the function and disorders of the gastrointestinal tract) should perform this procedure. This procedure is used more commonly to find cancer of the bile duct than to find gallbladder cancer, but it may also be used if the gallbladder cancer spreads and blocks the bile ducts. Percutaneous cholangiography. In this procedure, a thin needle is inserted through the skin and into the gallbladder area. A dye is injected through the needle so that a high-contrast image will show up on x-rays. By looking at the x-rays, the doctor may be able to see whether there is a tumor in the gallbladder. More commonly, a cholangiography provides images of the bile ducts and may not show a tumor in the gallbladder. However, it is excellent in detecting the site of a blocked bile duct. Laparoscopy. Laparoscopy uses an endoscope to look at the gallbladder and other internal organs. The tube is inserted through a small incision in the abdomen. Blood tests. The doctor may take samples of blood to check for abnormal levels of bilirubin and other substances. Bilirubin is a chemical that may reach high levels in people with gallbladder cancer due to blockage of the common bile duct by a tumor. CT scan. A CT scan creates a three-dimensional picture of the inside of the body with an x-ray machine. A computer then combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. Sometimes, a contrast medium (a special dye) is injected into a patient’s vein to provide better detail. Magnetic resonance imaging (MRI). An MRI uses magnetic fields, not x-rays, to produce detailed images of the body and can be used to find out whether the cancer has spread outside the gallbladder. A contrast medium may be injected into a patient’s vein to create a clearer picture. Ultrasound. An ultrasound uses sound waves to create a picture of the internal organs. Tumors generate different echoes of the sound waves than normal tissue, so when the waves are bounced back to a computer, creating images, the doctor can locate a mass inside the body. X-ray. An x-ray is a picture of the inside of the body. For instance, a chest x-ray can help doctors determine if the cancer has spread to the lungs. The patient may be asked to swallow barium, which coats the digestive tract, to enhance the image on the x-ray (called a barium swallow). Positron emission tomography (PET) scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into a patient’s body and absorbed by the organs or tissues being studied. This substance gives off energy that is detected by a scanner, which produces the images. Learn more about what to expect when having common tests, procedures, and scans. Find out more about common terms used during a diagnosis of cancer. Staging
Staging is a way of describing a cancer, such as where it is located, if or where it has spread, and if it is affecting the functions of other organs in the body. Doctors use diagnostic tests to determine the cancer's stage, so staging may not be complete until all the tests are finished. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient's prognosis (chance of recovery). There are different stage descriptions for different types of cancer. One tool that doctors use to describe the stage is the TNM system. This system uses three criteria to judge the stage of the cancer: the tumor itself, the lymph nodes around the tumor, and if the tumor has spread to other parts of the body. The results are combined to determine the stage of cancer for each person. There are five stages: stage 0 (zero) and stages I through IV (one through four). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments. TNM is an abbreviation for tumor (T), node (N), and metastasis (M). Doctors look at these three factors to determine the stage of cancer:
Tumor. Using the TNM system, the "T" plus a letter or number (0 to 4) is used to describe the amount of cancer found in the gallbladder. Some stages are also divided into smaller groups that help describe the tumor in even more detail. This helps the doctor develop the best treatment plan for each patient. Specific tumor stage information is listed below. TX: The primary tumor cannot be evaluated. T0: No evidence of cancer was found in the gallbladder. Tis: This classification is used when there is a condition called carcinoma (cancer) in situ. This means that the tumor remains in a pre-invasive state and its spread, if any, is very confined. T1: The tumor is in the gallbladder only and has only invaded the lamina propria (a type of connective tissue found under the thin layer of tissue covering a mucous membrane) or muscle layer. T1a: The tumor has invaded the lamina propria. T1b: The tumor has invaded the muscle layer. T2: The tumor has invaded the perimuscular connective tissue (the layer between the muscle layer and the serosa) but has not extended beyond the serosa (the outer layer) or into the liver. T3: The tumor extends beyond the gallbladder and/or has invaded the liver and/or one other adjacent organ or structure, such as the stomach, duodenum, colon, or pancreas. T4: The tumor has invaded the main portal vein or hepatic artery or has invaded more than one organ or structure beyond the liver. Node. The “N” in the TNM staging system stands for lymph nodes, the tiny, bean-shaped organs that help fight infection. Lymph nodes near the gallbladder are called regional lymph nodes. NX: The regional lymph nodes cannot be evaluated. N0 (N plus zero): There is no regional lymph node metastasis. N1: There is regional lymph node metastasis. Distant metastasis. The “M” in the TNM system indicates whether the cancer has spread to other parts of the body. MX: Distant metastasis cannot be evaluated. M0 (M plus zero): There is no distant metastasis. M1: There is metastasis to one or more other parts of the body. Cancer stage grouping Doctors assign the stage of the cancer by combining the T, N, and M classifications. Stage 0: Describes cancer in situ (Tis, N0, M0). Stage IA: A tumor is in the gallbladder only and has not spread (T1, N0, M0). Stage IB: A tumor has extended to the perimuscular connective tissue but has not spread elsewhere (T2, N0, M0). Stage IIA: A tumor has spread beyond the gallbladder but not to nearby arteries or veins. It has not spread to any lymph nodes or other parts of the body (T3, N0, M0). Stage IIB: The tumor of any size has spread to the lymph nodes, but not to nearby arteries and/or veins or to other parts of the body (T1, T2, T3; N1; M0). Stage III: The tumor has spread to nearby arteries, veins, and/or lymph nodes, but it has not spread to other parts of the body (T4, any N, M0). Stage IV: Describes any tumor that has spread to other parts of the body (any T, any N, M1). Recurrent: Recurrent gallbladder cancer is cancer that comes back after treatment. Used with permission of the American Joint Committee on Cancer (AJCC), Chicago, Illinois. The original source for this material is the AJCC Cancer Staging Manual, Sixth Edition (2002) published by Springer-Verlag New York, www.cancerstaging.net Treatment
The treatment of gallbladder cancer depends on the size and location of the tumor, whether the cancer has spread, and the patient’s overall health. In many cases, a team of doctors will work with the patient to determine the best treatment plan. This section outlines treatments that are the standard of care (the best treatments available) for this specific type of cancer. Patients are also encouraged to consider clinical trials when making treatment plan decisions. A clinical trial is a research study to test a new treatment to prove it is safe, effective, and possibly better than standard treatment. Your doctor can help you review all treatment options. For more information, visit the Clinical Trials section. Gallbladder cancer may be treated with one or more techniques including surgery, chemotherapy, or radiation therapy. If detected at an early stage, gallbladder cancer has a much higher chance of being successfully treated. A team of doctors, including a gastroenterologist, surgeon, medical oncologist, and radiation oncologist, may be involved in treatment planning. Descriptions of the most common treatment options for gallbladder cancer are listed below. Surgery A surgical oncologist is a doctor who specializes in treating cancer using surgery. The following are types of surgery used in the treatment of gallbladder cancer: Cholecystectomy. Also called a simple cholecystectomy, this procedure involves the removal of the gallbladder. An extended cholecystectomy is the removal of the gallbladder, one inch or more of liver tissue located next to the gallbladder, and all of the lymph nodes in the region. Radical gallbladder resection. This procedure involves the removal of the gallbladder, a wedge-shaped section of the liver near the gallbladder, the common bile duct, part or all of the ligaments between the liver and intestines, and the lymph nodes around the pancreas and nearby blood vessels. Palliative surgery. Surgery may sometimes help relieve symptoms caused by gallbladder cancer, even if the tumor cannot be removed. For example, surgery may relieve a blockage of the bile ducts or intestines. Learn more about cancer surgery. Radiation therapy Radiation therapy is the use of high-energy x-rays or other particles to kill cancer cells. A doctor who specializes in giving radiation therapy to treat cancer is called a radiation oncologist. The most common type of radiation treatment for gallbladder cancer is called external-beam radiation therapy, which is radiation therapy given from a machine outside the body. Radiation therapy may be used before surgery to shrink the size of the tumor or after surgery to destroy any remaining cancer cells. In some cases, radiation therapy is given during surgery to directly target the area of the tumor and protect healthy organs from the effects of traditional radiation therapy. This procedure is called intra-operative radiation therapy, or IORT. Side effects of radiation therapy may include fatigue, mild skin reactions, upset stomach, loose bowel movements, and damage to nearby structures such as the liver or intestines. Most side effects go away soon after treatment is finished. Learn more about radiation therapy. Chemotherapy Chemotherapy is the use of drugs to kill cancer cells. Systemic chemotherapy is delivered through the bloodstream, targeting cancer cells throughout the body. Chemotherapy is given by a medical oncologist, a doctor who specializes in treating cancer with medication. Some people may receive chemotherapy in their doctor’s office; others may go to the hospital. A chemotherapy regimen (schedule) usually consists of a specific number of cycles given over a specific time. Chemotherapy may be given before surgery to shrink the tumor or after surgery to destroy any remaining cancer cells. It also may be combined with radiation therapy. Chemotherapy can be given by mouth or injection. The drugs that are commonly recommended include gemcitabine (Gemzar) and fluorouracil (5-FU, Efudex). The side effects of chemotherapy depend on the individual and the dose used, but can include fatigue, risk of infection, nausea and vomiting, loss of appetite, and diarrhea. These side effects usually go away once treatment is finished. Learn more about chemotherapy and preparing for treatment. The medications used to treat cancer are continually being evaluated. Talking with your doctor is often the best way to learn about the medications prescribed for you, their purpose, and their potential side effects or interactions with other medications. Learn more about your prescriptions by using searchable drug databases. Find out more about common terms used during cancer treatment. Clinical Trials Resources
Doctors and scientists are always looking for better ways to treat patients with gallbladder cancer. A clinical trial is a way to test a new treatment to prove that it is safe, effective, and possibly better than a standard treatment. The clinical trial may be evaluating a new drug, a new combination of existing treatments, a new approach to radiation therapy or surgery, or a new method of treatment or prevention. Patients who participate in clinical trials are among the first to receive new treatments before they are widely available. However, there is no guarantee that the new treatment will be safe, effective, or better than a standard treatment. Patients decide to participate in clinical trials for many reasons. For some patients, a clinical trial is the best treatment option available. Because standard treatments are not perfect, patients are often willing to face the added uncertainty of a clinical trial in the hope of a better result. Other patients volunteer for clinical trials because they know that finding new drugs and other therapies is the only way to make progress in treating gallbladder cancer. Even if they do not benefit directly from the clinical trial, their participation may benefit future patients with gallbladder cancer. Sometimes people have concerns that, by participating in a clinical trial, they may receive no treatment by being given a placebo or a “sugar pill.” The use of placebos in cancer clinical trials is rare. When a placebo is used in a study, it is done with the full knowledge of the participants. Find out more about placebos in cancer clinical trials. To join a clinical trial, patients must participate in a process known as informed consent. During informed consent, the doctor should list all of the patient’s options, so the person understands how the new treatment differs from the standard treatment. The doctor must also list all of the risks of the new treatment, which may or may not be different than the risks of standard treatment. Finally, the doctor must explain what will be required of each patient in order to participate in the clinical trial, including the number of doctor visits, tests, and the schedule of treatment. Learn more about clinical trials, including patient safety, phases of a clinical trial, deciding to participate in a clinical trial, questions to ask the research team, and links to find cancer clinical trials. For specific topics being studied for gallbladder cancer, learn more in the Current Research section. Side Effects
Cancer and its treatment can cause a variety of side effects. However, doctors have made major strides in recent years in reducing pain, nausea and vomiting, and other physical side effects of cancer treatments. Many treatments used today are less intensive but as effective as treatments used in the past. Doctors also have many ways to provide relief to patients when such side effects do occur. Fear of treatment side effects is common after a diagnosis of cancer, but it may be helpful to know that preventing and controlling side effects is a major focus of your health-care team. Before treatment begins, talk with your doctor about possible side effects of the specific treatments you will be receiving. The specific side effects that can occur depend on a variety of factors, including the type of cancer, its location, the individual treatment plan (including the length and dosage of treatment), and the person’s overall health. Ask your doctor which side effects are most likely to happen (and which are not), when side effects are likely to occur, and how they will be addressed by the health-care team if they do happen. Also, be sure to communicate with the doctor about side effects you experience during and after treatment. Learn more about the most common side effects of cancer and different treatments, along with ways to prevent or control them. In addition to physical side effects, there may be psychosocial (emotional and social) effects as well. Learn more about the importance of addressing such needs, including concerns about managing the cost of your cancer care. Learn more about the late effects or long-term side effects by reading the After Treatment section or talking with your doctor. After Treatment
After treatment for gallbladder cancer ends, talk with your doctor about developing a follow-up care plan. This plan may include regular physical examinations and/or medical tests to monitor your recovery for the coming months and years. It is necessary to have regular checkups following treatment for gallbladder cancer to watch for possible recurrence. In addition to physical examinations, blood tests and imaging tests (for example, CT scans) may be done. People recovering from gallbladder cancer are encouraged to follow established guidelines for good health, such as maintaining a healthy weight, not smoking, eating a balanced diet, and having recommended cancer screening tests. Talk with your doctor to develop a plan that is best for your needs. Moderate physical activity can help rebuild your strength and energy level. Your doctor can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about healthy living after cancer. Find out more about common terms used after cancer treatment is complete. Current Research
Research for gallbladder cancer is ongoing. The following advances may still be under investigation in clinical trials and may not be approved or available at this time. Always discuss all diagnostic and treatment options with your doctor. Immunotherapy. Immunotherapy (also called biologic therapy) is designed to boost the body’s natural defenses to fight the cancer. It uses materials either made by the body or in a laboratory to bolster, target, or restore immune system function. Current clinical trials are testing immunotherapy as a way to treat gallbladder cancer. Gene therapy. Gene therapy is an experimental treatment that involves introducing genetic material into a person’s cells to treat cancer. Gene therapy is being studied in clinical trials for many different types of cancer and for other diseases. Chemotherapy and radiation therapy improvements. Currently, the effectiveness of chemotherapy and radiation therapy for the treatment of gallbladder cancer is limited. Clinical trials are evaluating new drugs for gallbladder cancer and trying to increase the effectiveness of radiation therapy. Questions to Ask the Doctor
Regular communication with your doctor is important for making informed decisions about your health care. Consider asking the following questions of your doctor. General questions:
Questions to ask before surgery:
Questions to ask before radiation therapy:
For patients who need chemotherapy:
After treatment:
Patient Information Resources
In addition to Cancer.Net, there are other sources of information about this type fo cancer available online. Cancer.Net maintains a list of national, not-for-profit organizations that may be helpful in finding additional information, services, and support. As always, be sure to talk to your doctor about questions you may have about information you find about this disease. View organizations that offer information on this specific type of cancer. |
