The study was conducted between September 19 and November 4, 2024, using a stratified random sampling method designed to capture the diversity of Chinese clinical practice. Respondents included 48 surgeons, 48 oncologists, and 24 interventionalists or radiotherapists drawn from tier 1, 2, and 3 cities, including Beijing, Shanghai, Guangzhou, Shenzhen, Wuhan, Chengdu, Xiamen, Fuzhou, and Wuxi. All participating hospitals were ranked secondary A or higher within China’s three-tier hospital classification system and each saw more than 100 patients with biliary tract cancer per year. The physicians averaged 16 years of experience in managing advanced disease, and two-thirds held the title of associate chief physician or above.

The clinical picture that emerged is sobering. Physicians estimated that 58.2 percent of patients with advanced biliary tract cancer are initially deemed to have unresectable tumors, meaning surgery, the only potentially curative option, is off the table from the start. Approximately half of patients present with locally advanced disease, while 44.4 percent have metastatic disease. Most respondents, 85.8 percent, indicated that between 30 and 80 percent of their patients have unresectable or metastatic disease at diagnosis, a figure consistent with the disease’s insidious onset. Because early-stage biliary tract cancer produces few or no symptoms, most patients are diagnosed only after the tumor has progressed beyond the reach of the scalpel.

The survey also documented a shift in the disease’s anatomical distribution. Respondents reported that intrahepatic cholangiocarcinoma, which arises within the liver’s bile ducts, was the most common subtype they encountered, accounting for an estimated 39.2 percent of cases, followed by extrahepatic cholangiocarcinoma at 34.6 percent and gallbladder cancer at 26.2 percent. That ordering differs from epidemiological data collected in China between 2008 and 2012, when gallbladder cancer was the most frequently diagnosed subtype. The authors suggest this shift may reflect changing risk factors, including hepatitis B and C infection, obesity, and diabetes, which have driven a rise in intrahepatic tumors.

On the treatment front, the survey found that physicians estimated 77.3 percent of patients with advanced disease receive first-line therapy, while 22.8 percent receive no antitumor treatment at all. Among those who are treated, immunotherapy combined with chemotherapy was the most commonly used first-line modality, selected by 34.2 percent of physicians, followed by chemotherapy alone at 15.8 percent and local-regional combination therapies at 10.8 percent. Yet guidelines from both China and the National Comprehensive Cancer Network recommend immunotherapy plus chemotherapy as the preferred first-line approach, based on phase 3 trials showing that adding durvalumab or pembrolizumab to gemcitabine and cisplatin improves survival compared with chemotherapy alone. Only about a third of surveyed physicians reported following that standard, exposing a substantial implementation gap.

The specific regimens physicians chose reveal further nuances. Gemcitabine plus cisplatin combined with immunotherapy was the most frequently used immunochemotherapy combination, cited by 52.4 percent of respondents, followed by gemcitabine plus oxaliplatin plus immunotherapy at 31.1 percent. The most commonly paired immunotherapy drugs were durvalumab, sintilimab, tislelizumab, and pembrolizumab. Notably, the survey found relatively high use of sintilimab and tislelizumab despite limited evidence supporting their use in biliary tract cancer, suggesting that real-world practice in China deviates from the evidence base in ways that may reflect drug availability and cost rather than clinical trial data. Targeted therapies, such as FGFR and HER2 inhibitors, remained rare in the first-line setting, used in combination with immunotherapy by only 4.2 percent of physicians.

Geography and economics clearly shape treatment decisions. Physicians in tier 1 and tier 2 cities were significantly more likely than those in tier 3 cities to cite patient baseline status and economic considerations as key factors in choosing an immunochemotherapy regimen, differences the authors attribute to uneven distribution of healthcare resources, hospital capacity, and access to novel therapies. The reasons physicians gave for choosing chemotherapy alone included disease characteristics, patient baseline status, economic considerations, and the evidence level of the regimen. The relatively poor tolerability of gemcitabine plus cisplatin, which is associated with nephrotoxicity, nausea, vomiting, and anorexia, may also explain why some clinicians opt for alternative chemotherapy backbones such as GEMOX.

The picture darkens further after first-line treatment fails. Physicians estimated that only 43.8 percent of patients proceed to subsequent therapy after disease progression, with the overwhelming majority of physicians, 94.2 percent, citing the patient’s inability to tolerate existing regimens as the main barrier. Economic constraints and medications falling outside insurance coverage were cited by 65 percent, and patient transfers to other hospitals by 63.3 percent. Among those who do continue treatment, immunotherapy plus chemotherapy was the most common subsequent modality, followed by chemotherapy alone and immunotherapy plus an anti-angiogenic agent. Existing second-line options offer only modest efficacy, underscoring what the survey’s respondents identified as the field’s most pressing unmet needs: a limited selection of treatment regimens, cited by 46.7 percent, and financial barriers to care, cited by 40 percent.

One of the most intriguing findings concerns conversion and downstaging therapy, an approach in which systemic treatment is used to shrink initially unresectable tumors enough to make surgery possible. Roughly 90 percent of surveyed physicians reported experience with this strategy, and most considered patients with technically resectable intrahepatic metastases, large tumors, or vascular invasion to be suitable candidates. Immunotherapy plus chemotherapy and triplet therapy combining immunotherapy, chemotherapy, and an anti-angiogenic agent were viewed as the most credible conversion regimens. However, most physicians estimated the success rate of conversion therapy at below 40 percent, and the authors caution that phase 3 trials are still needed to validate the efficacy and safety of this increasingly popular approach.

Biomarker testing emerged as another critical bottleneck in the pathway to precision medicine. Although 51.7 percent of physicians expressed high willingness to test patients for actionable gene mutations such as IDH1, HER2, and FGFR2, and for immune-related markers including PD-L1 and tumor mutational burden, only 63.3 percent reported that 20 to 50 percent of their patients were actually tested. High testing cost was cited by 93.3 percent of physicians as the main obstacle, and nearly all noted that the positive detection rate for both immune-related markers and actionable mutations was below 20 percent. Even among patients who tested positive, fewer than half, 41.5 percent, went on to receive biomarker-guided medication, primarily because of economic considerations, poor tolerability, and limited guideline support. Overall physician satisfaction with current treatment and management of advanced biliary tract cancer ranged from 6.1 to 7.5 out of 10, with the lowest scores assigned to overall efficacy and drug accessibility. The authors hope their findings will inform future standardization of care in China, where the incidence and mortality of this challenging cancer continue to rise.

Subject of Research: Treatment patterns and physician decision-making for advanced biliary tract cancer in China

Article Title: Patient Characteristics and Treatment Patterns of Advanced Biliary Tract Cancer (BTC): A Chinese Physician Survey

Article References: Qiu, H., Liu, Q., Wang, Z., Chen, W., Tang, W., & Hao, C. (2026). Patient Characteristics and Treatment Patterns of Advanced Biliary Tract Cancer (BTC): A Chinese Physician Survey. Advances in Therapy. https://doi.org/10.1007/s12325-026-03732-y

Image Credits: AI Generated

DOI: 10.1007/s12325-026-03732-y

Keywords: biliary tract cancer, cholangiocarcinoma, immunotherapy, chemotherapy, China, physician survey, biomarker testing, conversion therapy, gemcitabine, cisplatin, healthcare access, treatment guidelines