Rose McNulty

Small-cell lung cancer (SCLC) remains a challenging diagnosis for patients and physicians despite the progress made in more common non-small cell lung cancer (NSCLC) in recent years. With fewer targets and therapeutics available, mortality rates are low in SCLC compared with NSCLC.

Given the slower progress and fewer approvals, it is imperative that when there are updates on the research and regulatory side, physicians and patients are made aware of the options. The National Comprehensive Cancer Network (NCCN) produces guidelines across cancer types to help keep providers and even payers current on the drug armamentarium and optimal approaches for each patient.

The American Journal of Managed Care® (AJMC®) 

spoke with Kathryn Gold, MD, medical oncologist and associate professor of medicine at UC San Diego, who is a member of the NCCN guidelines panel for small-cell lung cancer, for insight into the guidelines and the importance of frequent updates.

The following has been edited lightly for clarity.

Can you discuss the need for frequent updates to NCCN guidelines as new therapies emerge in SCLC?

 As a committee, we really think it's important to update the guidelines frequently with the latest information. Our standard procedure is an annual meeting where we really go over the entire set of guidelines from page 1 until the end, look at all the details, and see if there's any irrelevant things that need to be removed, discuss if there are any new things that need to be added. But between those annual meetings, we also have ad hoc discussions whenever important new data comes available—either a phase 3 trial, exciting phase 2 trial with really promising results, a new FDA approval, or an FDA withdrawal of approval, as has happened recently with several drugs. We’ll meet in between those annual meetings to update the guidelines about that. Those can be emails, they can be conference calls, but we do think it's really important to keep that up to date, because we know that busy clinicians are making decisions for their patients based on the information in there. I'm fortunate that I get to focus on only a couple tumor types. I focus on lung, head, and neck cancer, so that's all the data I need to know. But many doctors in practice have to focus on all different tumor types, so they may not be able to stay quite as involved in the research on any one tumor type, especially relatively rare tumor like small-cell lung cancer. So we know that people are relying on us to get the most up to date data for their patients to be able to figure out how to treat them. We also know that some insurers use our guidelines, as part of their decision making regarding coverage decisions, we do try to keep it updated for that reason, as well.

 What are your thoughts on the recent withdrawals?

 Yeah, so this is related to the FDA’s desire to get things approved quickly if they look really promising based on early data, but sometimes that early data doesn't pan out. So the 2 recent examples in small-cell lung cancer were nivolumab and pembrolizumab. And they both got accelerated approvals based on phase 1 and 2 data showing promising response rates for small-cell lung cancer. Both those FDA approvals required them to do larger confirmatory phase 3 trials with overall survival endpoints. And on those phase 3 trials, the survival endpoints were not met. Therefore, the FDA approval was withdrawn. Now, those are still listed on the NCCN guidelines, both nivolumab and pembrolizumab, kind of with a lower preference ranking to reflect that withdrawal of FDA approval.

The SCLC treatment landscape has been slower to evolve than in NSCLC. As you look ahead, where do you see potential for progress?

 This has been a really disappointing thing in my career, and it's not for lack of effort. There have been a lot of good scientists, a lot of good clinical research done in small cell. But while we've seen really dramatic improvements in non-small cell lung cancer therapy in the past decade, as you mentioned, in small cell we have not seen such dramatic improvements. There have been some changes. We're now using immunotherapy, we're adding it to frontline chemotherapy for most of our patients. And that has a demonstrated overall survival benefit in 2 phase 3 trials right now. But other than that, how we treat small-cell lung cancer is really much of the same as how we treat it at the beginning of my career. I think, you know, scientifically, it's a different tumor, it tends to be a more rapidly progressive tumor, it doesn't seem to have the mutations that we can target. For example, in non-small cell lung cancer, we have mutations like 

 that we have really effective targeted therapies to combat. We don't see those same mutations in small-cell lung cancer, and we really haven't found anything that we can use those targeted therapies for.

As far as potential for progress, I still think immunotherapy is a really attractive area, but it's clearly not the right answer for everyone. So we need to figure out who immunotherapy works for and who it doesn't. I think combination therapies of immunotherapy and chemotherapy or immunotherapy and targeted therapy, or targeted therapy and chemotherapy, that also offers some potential for benefit. And I also think we need to really explore the subtypes of small-cell lung cancer. You know, we've known for a long time now that non-small cell lung cancer, it's not all one thing. We've been able to use molecular profiling to find mutations or overexpressed proteins in an individual patient's cancer, and we've been able to use that to tailor a treatment regimen for patients. That's led to better outcomes, it's led to lower toxicity. We're only now starting to explore those same subtypes in small-cell lung cancer, too. We know that not all small-cell lung cancers are the same, so I think in the future if we can target small-cell lung cancer not all as one group but as molecular subtypes, I think that'll help to improve outcomes.

Over the summer, the NCCN recommended lurbinectedin in the second-line setting for patients with SCLC, where there are still not many options for treatment. What makes this particular setting difficult to treat?

 The short answer is we don't know. The longer answer is that these are really aggressive tumors that tend to respond really well to chemotherapy at first. I mean, it's very gratifying to treat these patients in clinic at first, because you see someone coming in, they feel poorly, they have really a lot of tumor burden in their body. You start chemotherapy with platinum etoposide, sometimes with immunotherapy, and people feel better sometimes within days after starting chemotherapy. Normally, we do see a really dramatic response on CT scans to frontline chemotherapy as well, but the big problem is it doesn't last. We see these dramatic responses, but then months later the cancer comes back, and when it comes back to tends to be more aggressive. We do have some options in this setting—sometimes, we can go back to the first chemotherapy we used like platinum etoposide. Also, topotecan has long been an FDA approved option in this setting. But we know that the second-line treatments don't work as well as first-time treatments. Response rate rates aren't as high, and when responses do happen, they don't last as long, so we do definitely need more options for therapy there. Lurbinectedin was FDA approved based on phase 2 trial data with response rate data. This was another one of those accelerated approvals like we discussed with the FDA where it's going to be contingent upon a larger phase 3 trial. I think as far as the activity of lurbinectedin compared to topotecan, it's a slightly more convenient dosing. Topotecan requires 5 days of dosing every 3 weeks, whereas lurbinectedin requires just 1 day every 3 weeks, and it seems to be relatively well tolerated, so it's nice to have another tool in the toolbox. But this has been a landscape where we've seen so many drugs that have had promising data from phase 1 and phase 2 trials where we see response rates that look exciting, but then when it goes into a phase 3 data trial when it goes head to head versus topotecan, there have been so many drugs where it just hasn't panned out or those results have been negative— immunotherapy trials, antibody drug conjugate trials, chemotherapy trials, even though topotecan’s not a great drug and none of us love, it's been really hard to beat in phase 3 trials.

The guidelines note that typical lung cancer screening protocol have not proven effective when it comes to SCLC. What makes it so challenging, and do you see any potential ways to improve screening protocol for SCLC?

 Lung cancer screening has become so important for early detection of non-small-cell lung cancer. We do recommend that many people with tobacco history, either current or former smokers, do get a once-yearly low dose CT scan to screen for lung cancer. So far that's been mainly effective in diagnosing non-small cell lung cancer early, and I think the reason why it's been less effective at reducing mortality from small-cell lung cancer is because small-cell lung cancer really grows so rapidly and spreads so early on in its course that it's hard to find it in that window of time where it might be potentially curable before it spreads elsewhere. I think once a year having a scan, there's a chance that the small-cell could pop up in between scans, so unless you can find it in that really short interval between when it develops into a lung nodule versus when it spreads distantly, you're not going to really decrease the mortality. I think with other fast growing cancers that's been a problem with screening, as well—things like pancreatic cancer. So it’s very different from non-small-cell lung cancer, from breast cancer, or from colon cancer where they tend to be slightly slower growing tumors, so I don't think we're going to be able to find a screening strategy that's really going to reduce our mortality here. I think the most important thing is going to be prevention. We know that small-cell lung cancers are highly associated with tobacco use, both duration and intensity of use, as well as the age that people started smoking. So getting people to quit smoking, and more importantly, I think getting young people to not start smoking, is really going to be the key to reducing mortality from small-cell lung cancer.

Articles

Kathryn Gold, MD, medical oncologist and associate professor of medicine at UC San Diego, who is a member of the NCCN guidelines panel for small-cell lung cancer, gives insight into the guidelines and the importance of frequent updates.

Insights on Small-Cell Lung Cancer NCCN Guidelines

Clinical trials are an integral part of progress in cancer therapeutics, but it can be challenging to pull off large trials in rare diseases such as cholangiocarcinoma. At the 2021 Cholangiocarcinoma Foundation Annual Conference, experts discussed clinical trials in cholangiocarcinoma and the ways in which clinical trials overall can be made more available to patients.

Susan Pandya, MD, vice president of clinical development at Agios Pharmaceuticals, provided an example in the ClarIDHy study, a randomized phase 3 trial of ivosidenib. This therapy is already approved for the treatment of acute myeloid leukemia with 

mutation, and the study is examining its potential role in cholangiocarcinoma with the 

Ivosidenib’s development in cholangiocarcinoma began in 2014 with a phase 1 study and just saw the submission of a supplemental new drug application in February 2021. This timeline serves as proof that progress is possible in rare disease settings when industry, patient advocates, and the academic community work together, Pandya said.

“Operationalizing a study in a rare cancer has many challenges, and the feasibility is often raised as a gate for decision making,” she said. To mitigate this challenge, researchers cast a “broad net” across several countries to determine the feasibility and took a hands-on approach in maintaining momentum as they searched for motivated investigators. Around 200 sites were considered, 80 were interested, and 49 sites in 6 countries participated in the study.

This trial design also offered a pre-screening consent, which helped identify patients with 

 mutations early, Pandya said. That provided an opportunity for patients receiving first- or second-line chemotherapy during the pre-screening phase to later choose to join the trial. Of 780 pre-screened patients, 187 were eventually randomized.

To raise awareness, Agios extended reach to scientific conferences, engaged with advocacy groups to make information available to patients, and created print and web-based resources to create more awareness around the trial.

Balancing efficiency and inclusivity is another challenge in clinical trials and eventual drug approvals. Lola Fashoyin-Aje, MD, MPH, deputy director for the Division of Oncology 3 in the Office of Oncologic Diseases at the FDA, discussed drug development considerations that provide patient access and address a broader population.

“It’s important, particularly as more drugs are developed, to consider how we can expand the pool of patients who have access to these drugs, either through clinical trials or once they are approved,” Fashoyin-Aje said. The American Society of Clinical Oncology (ASCO) has been working to develop a framework to broaden trial criteria for about 5 years, she noted. Over time, criteria have become more and more restrictive, which is one reason why just around 3% to 5% of cancer patients take part in trials.

Broadening eligibility criteria can benefit both patients and researchers by early access to investigational drugs, faster trial accrual, more complete safety and efficacy data, earlier identification of drugs that may not be effective, and generalizable results, she said. But it can also pose risks, like greater heterogeneity limiting the interpretation of result. It may also be more difficult to identify efficacy signals and interpret safety. Safety concerns may also require more frequent patient monitoring.

Progress in adopting new suggested frameworks has been slow, Fashoyin-Aje said. The FDA has taken a proactive approach trying to operationalize ASCO’s framework in disease-specific contexts, including cholangiocarcinoma. The key points in vetting current trial criteria are identifying those considered important in all trials as well as those used frequently that may not be appropriate.

There is tension between drug development efficiency and studying more diverse populations. FDA has encouraged measures like enrolling a cohort of patients that can be analyzed for the primary analysis as well as a cohort of patients that, based upon relaxed criteria, can provide information on different dosages either once the drug is approved or shortly thereafter.

In rare disease settings, platform trials and common control groups can also help promote efficiency. Another potentially huge barrier, trial-associated burdens involving things like travel to large academic centers, needs to be addressed, she added. It can take innovation, such as leveraging technology; using telemedicine and eConsent; decreasing procedures when feasible; and decentralizing trials, allowing patients to get things like lab work done locally rather than at the large center where the trial may be based.

“That’s something that we’ve been discussing well before the COVID 19 pandemic and trying to develop some guidance around that,” Fashoyin-Aje said during a post-presentation panel discussion. “Part of what has been identified is the intensity and frequency of these clinical trial requirements.” 

She noted that it can be a virtually full-time commitment to take part in a trial—something that some patients just cannot manage. And especially with drugs that are already approved for other indications that have been proven to have a tolerable safety profile, intensive monitoring is not as necessary.

Another growing aspect of research and clinical practice, patient-reported outcomes (PROs) can also be used to complement clinical evaluations, since they directly reflect symptomatic adverse events patients are experiencing. This practice can help with dose optimizations earlier on and avoid clinical holds due to uncertainly about optimal dose later, Fashoyin-Aje said.

“Adoption of practices that improve access and facilitate adherence to clinical trials and that help generate data that are generalizable is really critical to improving outcomes for all patients,” she concluded. “Sponsors should employ rational and streamlined eligibility criteria, flexible trial design and analyses, and multi-pronged and multi-staged approach to dose optimization.”

At the 2021 Cholangiocarcinoma Foundation Annual Conference, experts discussed clinical trials in cholangiocarcinoma and the ways in which clinical trials overall can be made more available to patients.

Overcoming Challenges in Clinical Trials for a Rare Cancer

With rare diseases such as cholangiocarcinoma, one potential barrier to receiving optimal care is the fact that given their rarity, medical staff outside of a patient’s cancer care team, such as emergency department staff, may not be up-to-date on best practices and optimal approaches for treatment. When a patient with cholangiocarcinoma who has a biliary stent or drain presents in an emergency department with symptoms of biliary obstruction, for example, it can be a complicated situation for staff who does not often deal with such complications in this specific patient.

At the 15th Cholangiocarcinoma Foundation Annual Conference, Juan Valle, MD, professor of medical oncology at the University of Manchester and medical oncologist at the Christie NHS Foundation Trust, gave an overview of biliary obstruction before discussing guidelines for the management of urgent symptoms in patients with cholangiocarcinoma who have biliary stents or drains. Biliary obstruction, or blockage of the bile ducts, can be caused by cholangiocarcinoma tumors and is potentially life-threatening or even deadly if not managed.

Signs of biliary obstruction include malaise, jaundice, itching, pale stools, dark urine, and fevers when there is an infection. Blood tests can also identify it, and radiological scans can confirm the obstruction and identify the location of the blockage. Coming up with an efficient and effective plan to stabilize the patient and relieve the obstruction is important, Valle explained, because it can become an emergency.

Endoscopic retrograde cholangiopancreatography (ERCP) and percutaneous trans-hepatic cholangiography (PTC) are both treatment methods to get bile flowing again, which is the top priority after a blockage is identified. A stent or drain can be used to ensure the flow does not get blocked again, but that is not the end of the story.

“Once in place, stents and drains are highly prone to getting clogged by tumor ingrowth, which means that a tumor grows in along some of the holes in the mesh and that then causes a blockage of the small bile ducts,” Valle explained. “Bile can be gritty, which is why people get gallstones, so you can develop sludge or indeed gallstones. And you can also get superadded infection on top of that.”

He then got into detail about the Delphi Process, which was an initiative to develop “consensus guidelines for the management of cholangiocarcinoma patients with a biliary stent or catheter in place who present for emergency management in the outpatient acute setting.” Physicians, nurses, interventional radiologists, and oncologists from academic and community hospitals made up the consensus panel.

The guidelines assume that a patient has recovered post-surgery, has access to the necessary care, may receive a higher level of care if needed, that they are not terminal and do not have a “do not resuscitate order” in place. They also would not be awaiting liver transplant, had access to palliative care and counseling, would be under active management by an oncologist, had all necessary tests, and that any recommendations for antibiotics are outside of the procedure at hand.

A literature review identified important variables, including bilirubin levels, liver function levels, fever, white blood cell count, ECOG performance status, biliary tract imaging findings, antibiotic recommendations, whether or not stent manipulation was recommended, and whether patients were actively on other treatment such as chemotherapy.

The broader recommendations broke down into 2 main categories: patients with normal bilirubin levels, and patients with elevated bilirubin.

In patients with elevated bilirubin, they determined that:

For patients with a fever, inpatient antibiotics are appropriate; however, in patients with no new or worsening biliary dilatation, outpatients may be an appropriate alternative, unless they present with neutropenia

Inpatient antibiotics may still be appropriate in a patient without a fever but with elevated white blood cells or neutropenia following chemotherapy; however, the panel was unsure if outpatient antibiotics are an appropriate alternative

A patient without a fever and with a normal white blood cell count does not need antibiotics

Stent manipulation is appropriate in patients with new or worsening biliary dilatation, fever, and a good ECOG performance status; but it is not appropriate in patients with no new or worsening biliary dilatation

For patients with a fever, inpatient antibiotics are appropriate; unless a patient has neutropenia, then outpatient antibiotics may be an appropriate alternative

If a patient with no fever has new or worsening biliary dilatation and is neutropenic or has an elevated white blood cell count, inpatient or outpatient antibiotics may be appropriate

A patient with no fever and a normal white blood cell count does not need antibiotics

The guideline was published in the journal 

in 2020, and emergency information cards are also available for patients to have on hand in case of an emergency room visit to inform physicians.

Renuka Iyer, MD, of Roswell Park Comprehensive Cancer Center in Buffalo, NY, took over to discuss real-world emergency department data for cholangiocarcinoma patients. Data from Komodo Health’s claims database was used to pull data from a 5-year period (2016-2020) for all cholangiocarcinoma diagnostic codes. They included patients with 2 or more encounters, amounting to 124,056 total patients. There were nearly 3 million unique encounters overall.

Findings included that intrahepatic cholangiocarcinoma patients made up the majority of the patients (62%) and that 18,203 were classified as both “not otherwise specified” biliary cancer and intrahepatic cholangiocarcinoma, highlighting the need for accurate documentation to collect data on these patients. The analysis also found that the majority of patients were diagnosed in the community setting (55,938 vs, 45,506 in academic settings) but that 22,612 were classified as unknown. More work is needed to classify those patients, Iyer said.

When cholangiocarcinoma patients presented in the emergency department or urgent care, Iyer pointed out that frequent diagnoses were elevated white blood cell count, fever, dehydration, and other symptoms of cholangitis. Yet, cholangitis itself fell much lower on the list. The same went for patients with cholangiocarcinoma with stents and tubes, although cholangitis was higher on the list.

Another highlight in the data regarding claims for cholangitis was that intravenous antibiotics were prescribed for cholangiocarcinoma patients with stents at a rate of about 41%, but the majority of providers caring for patients when they had cholangitis were not oncology subspecialists. According to the data, only about 5% 

“These are folks that we need to reach and perhaps spread this information or alert about this complication,” Iyer said. One important message for urgent care centers, she said, is that they need to be aware of cholangiocarcinoma as a cause of biliary obstruction, as well as standards for proper stent management. Carrying a card with information like the card discussed by Valle is one way patients can potentially assist medical staff, Iyer added.

“The last takeaway message here for the cholangiocarcinoma community is that we need to continue the efforts that we have started already to raise awareness of the diagnosis, including the importance of coding properly, so we can identify these patients and do this kind of work,” Iyer concluded. “And also use of the consensus guidelines that you just heard about for optimal management of our patients with cholangiocarcinoma.”

At the 2021 Cholangiocarcinoma Foundation Annual Conference, experts discussed guidelines and real-world data for the management of urgent symptoms in patients with cholangiocarcinoma who have biliary stents or drains.

Management of Biliary Obstruction in Patients With Cholangiocarcinoma

Day 1 of the Annual Cholangiocarcinoma Foundation Conference, now in its 15th year, saw a patient-focused agenda featuring experts from around the world. Topics ranged from COVID-19 and the advances made despite the pandemic to clinical conversations and perspectives from both patients and caregivers.

At the start of the conference, things were kicked off by co-chairs John Bridgewater, MD, PhD, of the University of Central London Cancer Institute; and Funda Meric-Bernstam, MD, of The University of Texas MD Anderson Cancer Center.

Bridgewater discussed the impact that the COVID-19 pandemic has had on research and on patients with cholangiocarcinoma. Although some cancer patients, including those with hematologic malignancies and lung cancer, fared worse when infected with COVID-19, cholangiocarcinoma patients on chemotherapy did not seem to be disproportionately susceptible to serious COVID-19 infection.

In the long term, there is not yet ample data to determine the long-term effects of the pandemic on patients with cholangiocarcinoma. “It will be probably years before we’re able to fully assess the impact of COVID on health services and, consequently, the ability to diagnose cholangiocarcinoma during the pandemic,” he said. Even so, there was a definite drop in diagnosis and services during the first lockdown.

Another change that occurred during the pandemic was the boom in telemedicine, which swept oncology and other facets of health care by storm as it became the safest way to engage with patients.

Huge downsides of the lockdowns in the UK were a pause in clinical trials during the first lockdown, which have since commenced; and that research funding, largely coming from charity in normal times, virtually disappeared during the first lockdown and has yet to return, Bridgewater said.

Despite the challenges, progress was still made over the past year, as Meric-Bernstam emphasized in her part of the discussion, which focused on advances in cholangiocarcinoma that have largely involved genomics and precision medicine.

She provided a brief overview of the genetic code, genomic alterations, oncogenes, mutations, and gene fusions before digging in to one gene fusion in particular that has been

“We talk a lot about genomically informed targeted therapy, talking about using this information about mutating genes, copy-number changes, and fusions to better identify therapies. This is all very relevant, especially for biliary tract tumors, because we’ve really discovered that there are several genes that we think drive the growth of cancers,” Meric-Bernstam said.

In intrahepatic cholangiocarcinoma, those include 

mutation, she noted. Gallbladder cancer and extrahepatic carcinomas, she pointed out 

It was an exciting year thanks to the FDA approval of pemigatinib, an FGFR inhibitor indicated for cholangiocarcinoma, Meric-Bernstam explained. It is the first targeted treatment in this cancer type, and the research supporting the approval showed 35.5% of patients with 

fusions of rearrangements had an objective response.

“This is the first approval for a genomically informed therapy for cholangiocarcinoma. 

is clearly proven to be a target of cholangiocarcinoma. And interestingly, there are several other FGFR- targeted therapies in development,” she said. The success of this trail, she added, shows that even in a disease as rare as cholangiocarcinoma, there can be successful, international trials and rapid accrual to move research along.

Genomic testing should be the standard of care in this cancer type, she said, as emerging data adds to discussions of potential targets. Liquid biopsies are also an emerging technology in cancer that may be able to help determine mechanisms of drug resistance. Meric-Bernstam also highlighted the potential importance of repeat biopsies throughout treatment, both liquid and from tumor tissue.

Overall, the expansion of precision oncology is a key aspect of the past year and where Meric-Bernstam sees cholangiocarcinoma treatment going in the future.

Mark Ghobrial, MD, PhD, director of the Houston Methodist J.C. Walter Jr. Transplant Center, picked up the discussion with topics in liver transplantation for intrahepatic cholangiocarcinoma.

Traditionally, resection. of part of the liver has been the strategy when this cancer presents in the liver, but less than 30% of patients present with resectable tumors, he said. Chemotherapy has seen many advances and can also be an effective approach, particularly gemcitabine and cisplatin, but progress has not been rapid in that area, either.

More recent research in transplantation, which was first met with some resistance, has shown success compared to resection, he said. One study showed that transplantation led to more success than resection, and also examined where chemotherapy fits into the picture. Compared with patients who received only chemotherapy or who received chemotherapy after transplant, those who received chemotherapy before the transplant did much better.

Tumor size also mattered in the success rate of transplant, with recurrence rates much lower with tumors less than 2 centimeters versus those greater than 2 centimeters, according to other research, Ghobrial said. The difference in 5-year survival was significant, with about 70% of patients with tumors less than 2 centimeters surviving in 5 years compared with about 40% in the larger tumor group.

“Let's look at the lessons from the previous literature that neoadjuvant therapy or chemotherapy given before transplantation is very effective when combined with a liver transplant,” Ghobrial said. “Liver transplant for selected patients can be successful. The question is: Who are the patients that should be selected for transplant?”

He and his team conducted research on transplantation, considering patients with unresectable disease eligible after 6 months of neoadjuvant therapy, which they used as a surrogate marker that the tumor was amenable to treatment. Presenting scans, he showed that transplantation led to better outcomes, although the study was very small.

Still, based on the results of the case series, which first included 7 transplants but now numbers about 17, liver transplant has potential in cholangiocarcinoma.

“Twenty years ago, the first results were very poor. Today, liver transplantation has become the preferred methodology for hepatocellular cancer or hepatoma,” Ghobrial said. “So liver transplantation can be performed successfully in patients with unresectable intrahepatic cholangiocarcinoma with excellent outcomes—within 60% or 80% survival 5 years out after this after this diagnosis is very good compared to any other modality. Liver transplant exhibits survival advantage compared with resection at any stage.”

Discussions at the start of the 2021 Annual Cholangiocarcinoma Foundation Conference centered on challenges and advances made during the COVID-19 pandemic, and the potential of liver transplantation in cholangiocarcinoma. 

Rose McNulty

Articles

Insights on Small-Cell Lung Cancer NCCN Guidelines

Overcoming Challenges in Clinical Trials for a Rare Cancer

Management of Biliary Obstruction in Patients With Cholangiocarcinoma

Recent Advances and New Methodologies in Cholangiocarcinoma