Cancer recurrence remains a significant hurdle in our quest to find a cure for cancer. The question of why some patients experience recurrence while others do not still remains a mystery. 

At present, the approach to predicting recurrence is largely based on statistical data. Physicians can primarily refer to the risk of recurrence of a particular cancer in the medical literature and devise a monitoring strategy accordingly. 

Recurrence is a significant problem in intrahepatic cholangiocarcinoma (CCA), which accounts for around 5%-10% of primary liver cancers. Its prevalence around the globe appears to be rising, probably due to better diagnostic protocols. The only curative option for this cancer remains surgical resection with negative margins. 


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“However, even with successful resection combined with adjuvant systemic chemotherapy, 5-year survival has ranged between 25%-43% due to the high rate of recurrence,” Bekki and colleagues wrote in Frontiers in Oncology. “While the median survival after recurrence is approximately 12 months, there is increasing evidence that aggressive multimodality treatment including re-resection may prolong survival in selected patient populations.” 

Read more about cholangiocarcinoma etiology 

Hence, surgical resection is no guarantee that a recurrence will not occur, and patients are usually advised of this as part of their signed consent preoperation.

Risk Factors for Recurrence

Much of the medical literature on intrahepatic cholangiocarcinoma has been devoted to understanding the risk factors for developing it and for later recurrence. 

Let’s start with the risk factors for developing intrahepatic cholangiocarcinoma. They are mostly related to pre-existing hepatic damage, such as primary sclerosing cholangitis, cirrhosis, and viral hepatitis. These diseases are also risk factors for cancer recurrence after resection. 

“Additionally, the presence of underlying liver disease can limit the ability to perform major resection which is often necessary in [intrahepatic cholangiocarcinoma] to achieve oncologically optimal results,” Bekki and colleagues wrote. 

Upon resection, surgeons are able to determine gross characteristics such as the size of the tumor, surgical margin status, as well as vascular and regional lymph node invasion. Generally, the more widespread the disease, the higher the risk of recurrence. Researchers have proposed various nomograms aimed at predicting the risk of recurrence based on tumor-related characteristics. 

A controversial aspect of intrahepatic cholangiocarcinoma care is whether lymphadenectomy has any impact on postoperative survival. The current recommendation by the American Joint Committee of Cancer is to conduct a lymphadenectomy with a minimum retrieval of 6 lymph nodes. 

“However, given the complex pattern of lymphatic flow from the liver, complete regional lymphadenectomy is challenging,” Bekki et al wrote. 

Some studies suggest that lymphadenectomy does not significantly prolong survival; other studies are more positive, suggesting it has a significant therapeutic effect. In addition, studies indicate that patients who received lymphadenectomy are more likely to receive adjuvant chemotherapy. 

An Ever-Present Threat 

One of the reasons cancer recurrence remains such a vexing problem is that it causes considerable anxiety among patients with cancer. Medical literature on the impact of cancer on the quality of life demonstrates that cancer is overwhelmingly viewed as a life-altering diagnosis. 

There are many possible reasons for this. One, of course, is statistical data: most patients with cancer suffer from some deterioration in their quality of life; in addition, survival is significantly reduced if the cancer has metastasized. 

If a tumor is still deemed resectable, there is still the worry that the cancer may return. This presents a double setback for patients: having to deal with the initial diagnosis, and subsequently having to deal with the open-ended possibility of recurrence. 

“Recurrence is a difficult stage in the cancer journey as it brings to the fore the life-threatening nature of the illness,” Wanat and colleagues wrote in Psycho-Oncology. 

Read more about cholangiocarcinoma treatment 

Wanat and colleagues conducted a meta-ethnography examining patients’ experience with cancer recurrence. They discovered that patients often experience emotional turmoil following the initial diagnosis as they grapple with an altered future. In addition, the risk of recurrence means that patients need to find strategies to help them live with this new sense of uncertainty. Some patients struggle with having to face death-related concerns and related consequences. 

Hence, research tackling cancer recurrence rates is important for 2 reasons: first, it saves lives; second, it relieves the considerable psychological disease burden experienced by cancer patients. 

Of course, we need not wait until cancer recurrence is completely eliminated before taking action. Psychiatric support is vital and should always be offered, even if patients do not seem distressed on the surface. Patients should be fully equipped to deal with both the medical and psychological consequences of living with cancer. 

“Healthcare professionals can promote a positive experience of care and help lessen the psychosocial impact of recurrence by providing information in an approachable way and being sensitive to their changing needs,” Wanat and colleagues wrote. 

In addition, patients should be supported in the one area of life that we often take for granted: a sense of control over one’s own body and destiny. In this regard, compassion is a quality that every oncologist must possess. As physicians, we must always aim to offer holistic care to all our patients. 

References

Bekki Y, Von Ahrens D, Takahashi H, Schwartz M, Gunasekaran G. Recurrent intrahepatic cholangiocarcinoma – reviewFront Oncol. 2021;11:776863. doi:10.3389/fonc.2021.776863

Wanat M, Boulton M, Watson E. Patients’ experience with cancer recurrence: a meta-ethnographyPsychooncology. 2016;25(3):242-252. doi:10.1002/pon.3908