Care Facility Type Tied to Biliary Tract Cancer Resection Outcomes

A national retrospective analysis recently published in the Journal of Gastrointestinal Cancer has uncovered disparities in biliary tract cancer (BTC) resection outcomes by care facility type, necessitating targeted strategies to expand access to specialized expertise and resources across oncology care settings.¹

A key finding of the study was that treatment at academic centers was independently associated with a higher likelihood of achieving complete oncologic resection and consequently improved overall survival (OS) for patients with BTC compared with nonacademic settings. After adjusting for age, comorbidity burden, and tumor stage, only comprehensive community cancer programs had significantly lower odds of achieving complete oncologic resection compared with academic centers (OR, 0.82; 95% CI, 0.74-0.90). Estimates for both community cancer centers and integrated network programs did not reach statistical significance.

Given the technical complexity of hepatobiliary surgery and the aggressive nature of these malignancies, these findings may reflect the concentration of certain facility-level factors, such as hepatobiliary surgical expertise, multidisciplinary teams, and perioperative resources that are more commonly available at high-volume academic institutions.

Furthermore, despite the advantage observed in academic centers, benchmarks for adequate lymphadenectomy were underperformed across facility types, highlighting opportunities to improve surgical quality across all facility types.

Importantly, these findings suggest that facility-level infrastructure and access to specialized hepatobiliary expertise are critical determinants of patient prognosis. Treatment at nonacademic centers remained associated with a 17% increase in mortality (HR, 1.17; 95% CI, 1.12-1.23) compared with academic centers.

“Our findings suggest [2] complementary strategies to help address observed disparities in BTC surgery. First, strengthening referral pathways to academic centers, where coordinated expertise is associated with higher rates of complete oncologic resection and superior survival,” proposed authors Lal et al in their conclusion.¹ “Second, elevating surgical quality across all facilities through standardized nodal staging protocols is essential, given the persistently low rates of adequate lymphadenectomy even at academic programs.”

Disparities in Care Quality

The study also revealed troubling trends regarding who are and are not achieving optimal surgical outcomes. Minority populations, including Black and Hispanic patients, had 19% (OR, 0.81; 95% CI, 0.71-0.93) and 18% (OR, 0.82; 95% CI, 0.72-0.94) lower odds, respectively, of achieving a complete oncologic resection than non-Hispanic White patients.

Additionally, patients at academic centers generally traveled farther for care compared with patients at nonacademic sites (median distance, 19.1 miles vs 9.5 miles), suggesting that geographic and financial constraints may prevent high-risk patients from accessing specialized institutions.

These findings suggest that the survival gap in BTC is not only a matter of surgical technique, but also a reflection of systemic barriers to high-volume, specialized oncologic care.

Study Design and Methodology

Data were derived from the National Cancer Database to identify patients diagnosed with BTC in the US, including intrahepatic and extrahepatic cholangiocarcinoma and gallbladder cancer, who underwent curative-intent surgical resection between 2004 and 2022. Procedures encompassed hepatic and bile duct resections, pancreaticoduodenectomy, cholecystectomy with regional lymphadenectomy, and combined organ resections.

Investigators identified 13,250 adult patients, about half (51.6%) of whom were treated at academic centers, and the remaining treated at nonacademic centers such as comprehensive community cancer programs (26.2%), integrated network cancer programs (18.9%), and community cancer programs (3.4%).

The primary objectives of the study were to evaluate the association between facility type—categorized as academic centers vs nonacademic centers—and complete oncologic resection, a composite measure defined as the presence of both a microscopically negative margin (R0) and adequate lymphadenectomy. OS was a secondary end point.

Implications for Care

The findings from the study reinforce not only the importance of early referral to high-volume centers for patients with suspected or confirmed biliary malignancies, but also policies that ensure greater allocation of resources to community settings in order to alleviate both provider burden and the financial and logistical burdens of travel for patients seeking care. Community oncology practices often serve as the first point of contact for patients and play a key role in providing more convenient, affordable, and high-quality care.

“We have shown that our site of care, away from expensive venues like hospital systems, hospital clinics, and ED [emergency department] visits, is an important way to control cost,” said Lucio Gordan, MD, Florida Cancer Specialists & Research Institute, in a recent interview with Targeted Oncology. A recent study by Gordan has demonstrated that community oncology practices deliver clinically equivalent care at a substantially lower cost than hospital-based settings.² Given the accessibility of community practices, shifting the site of care to locations more proximal to patients can help mitigate financial toxicity, ultimately giving rise to better outcomes.

Furthermore, the study highlights the need for standardized surgical quality metrics across all facility types. While not every patient can travel to an academic center, the implementation of multidisciplinary tumor boards and the adoption of standardized staging and treatment guidelines may help bridge the gap. This places community practices in a critical position to facilitate early diagnosis and multidisciplinary evaluation when complex hepatobiliary surgery is indicated.

For patients with BTC, the first surgical attempt represents the best opportunity for a cure; therefore, ensuring that this attempt occurs in an environment optimized for oncologic success is paramount.

REFERENCES

1. Lal T, Dong W, Abul-Khoudoud SO, et al. Facility type predicts completeness of oncologic resection and survival in biliary tract cancers. J Gastrointest Cancer. 2026;57(1):47. Published 2026 Feb 19. doi:10.1007/s12029-026-01421-1

2. Gordan L, Singh-Bulkan HHN, Warner A, et al. The role of utilizing community oncology care to decrease cancer-related financial toxicity. Am J Public Health. 2025;14(1):1‑7. doi:10.52338/tajoph.2025.5171