This project aims to steer uptake of genomic testing, monitoring and driving targeted chemotherapy informed by genomic testing in the Biliary Tract Cancer management (BTC) pathway at Nottingham University Hospitals (NUH) NHS Trust.
What have we done?
A team at Nottingham University Hospitals (NUH) NHS Trust, on behalf of the East Midlands region, have:
- collected/audited the past 2-3 years of genomic data on BTC patients who received palliative chemotherapy,
- established a standard regional BTC pathway to drive widespread adoption and acceptance of genomic testing among hepato-bilary (HPB) MDTs
- disseminated information through organising a regional teaching event.
Why did we undertake this project?
Biliary Tract Cancer, a rare cancer of unmet need with limited treatment options and poor prognosis, poses significant challenges, and the NHS mission is to leverage cutting-edge genomics to tailor treatment strategies.
NICE recommends Larotrectinib for treating NTRK fusion-positive solid tumours (27 May 2020), Pemigatinib for relapsed or refractory advanced cholangiocarcinoma with FGFR2 fusion or rearrangement (25 Aug 2021), Pembrolizumab for previously treated biliary cancer with high microsatellite instability or mismatch repair deficiency (20th Sep 2023) and Ivosidenib as an option for treating locally advanced/ metastatic cholangiocarcinoma with an IDH1 R132 mutation in adults after 1 or more systemic treatments (14 Dec 2023).
Targeted therapies optimise efficacy and minimise side-effects. These tests are now done in-house at NUH.
This project will be a transformative step towards precision medicine in BTC care, improving patient outcomes by integration of genomics into BTC management pathway.
Who have we worked with?
Our goal was to ensure regional HPB teams are committed to advancing cancer care and recognise the transformative potential of genomic testing in personalised medicine.
The NUH-based team that delivered this project included:
- Project Lead, Arvind Arora,
- East GMSA Medical Lead, Guru Aithal
- HPB MDT Lead, Suresh Venkatachalapathy
- Pathology GLH lead, Tom Mcculloch
- Data collectors/analysts (Oncology SpR)
- Regional HPB Oncologists, Sean Dulloo and Catherine Shankland
- Senior Pharmacist, Emma Dring
Project outputs
- Production of a new BTC Pathway for the East Midlands
- Analysis of retrospective BTC data completed
- Held a Regional Educational Event to share project findings and outputs
Conclusions on integrating Genomic Testing into BTC management
The project highlights significant gaps in the current genomic testing practices for BTC patients and provides a roadmap for integrating these tests into standard care.
Through educational initiatives, standardized pathways, and ongoing audits, the adoption of genomic testing can be improved, leading to more personalized and effective treatments for BTC patients.
Suboptimal uptake in the past 3 years may be due to reasons including:
- drugs were only approved recently (e.g. Ivosidenib was approved in December 2023 for IDH1 mutated BTC and Pembrolizumab in September 2023 for MSI-H BTC)
- drugs indicated only in second line setting
- insufficient tissue available for testing in some cases; and
- deterioration in Performance status of patients post first line therapy making them unsuitable for any further treatment.
We should now aim to significantly improve this uptake as drugs are NICE approved and upfront testing means patients would be able to access drugs straightway after progression on first line therapy improving their experience and outcomes.
Please expand the headings below to read more about the main project conclusions.
Meet our team
- Dr Arvind Arora, Project Lead ( Lead HPB Oncologist & Honorary Professor of Medical Oncology, Nottingham University Hospitals NHS Trust) (Arvind.Arora@nuh.nhs.uk)
- Col Spencer, PMO Support, EGMSA (colin.spencer@nuh.nhs.uk)