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Dr Michael D’Angelica on the Importance of NCCN Guideline Updates and Progress in Hepatobiliary Cancer


Michael I. D'Angelica, MD, FACS, director of the Hepatopancreatobiliary Fellowship Program at Memorial Sloan Kettering Cancer Center, discusses the NCCN guidelines for hepatobiliary cancers.

Michael I. D'Angelica, MD, FACS, Enid A. Haupt Chair in surgery; director of the Hepatopancreatobiliary Fellowship Program; and director of the Surgical Oncology Fellowship Program at Memorial Sloan Kettering Cancer Center, discusses the National Comprehensive Cancer Network (NCCN) guidelines for hepatobiliary cancers. D'Angelica is vice chair of the guidelines panel, which updates the recommendations regularly as new therapies and strategies emerge in the treatment of these cancer types.


Can you discuss the importance of annual updates to NCCN guidelines as new therapies emerge?

I think the annual review and the updates are critical. While, at times, medical improvements may seem to come slowly, at times they come quickly. And we've definitely seen this in the hepatobiliary guidelines, largely with the improvement in genomics and targeted therapies based on genomics, as well as [several] new systemic therapies that been recently proven to be effective. And so I can say that from when I first started working on these guidelines, they've changed dramatically over the last 10 years or so. The annual review of evidence—and the annual review of new drugs or new operations or new indications for certain procedures—has really been amazing. And I think it's absolutely critical that you continually re-review this, with the experts that we have.

There have been changes in the hepatobiliary cancer treatment landscape throughout the past year, with one example being targeted therapies gaining FDA approval and NCCN recommendation for bile duct cancer. Looking forward, where do you see potential for more progress?

This is a fascinating part of oncology right now. Historically, we have grouped cancers according to the organs that they originate in. They look similar under the microscope, and they usually behave similarly, but there's always been exceptions. And we're starting to realize—and this is throughout the whole landscape of cancer, I cannot say this is just specific to hepatobiliary cancers, although it's a bit prominent in that field right now—we're starting to realize [the importance of] certain mutations in the DNA of the tumor. I should specify that does not mean that's an inherited gene, that's a gene that became abnormal in the tumor itself. It could be related to something inherited, or more commonly, it's not, actually. But those alterations in the genes in the tumor sometimes make those tumors susceptible to very specific kinds of drugs. Basically, that leads to a situation where the genetic alteration sometimes becomes more important than the organ of origin of the tumor. So for example, if you have a bile duct cancer that happens to have a specific genetic alteration, you might treat it with a drug that's really not typically used at all for bile duct cancers because of that genetic alteration. And that we've seen a lot in all cancers, but we've certainly seen them very specifically in cholangiocarcinoma and even a little more specifically intrahepatic cholangiocarcinoma. Those are in development and they're going to change every year, and it also speaks back to the idea of continually reassessing these issues.

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