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15 standard-of-care settings across 5 lines and 2 biomarker subgroups. Rows come from the cancer page's standard of care; the grid places each on its line and subgroup.
| Line | All comers | HER2 |
|---|---|---|
| Screening, prevention and diagnosis | 2 | · |
| Advanced, first line | 2 | 1 |
| Second line | 1 | · |
| Third line and beyond | · | 1 |
| Other settings | 8 | · |
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| All comers | Diagnosis and staging | Ultrasound, contrast CT, MRI with MRCP, FDG PET-CT before radical surgery, staging laparoscopy; frozen section rather than needle biopsy when the mass is resectable. | 92 | ||
| All comers | Polyps and precursors (prevention) | Cholecystectomy for polyps of 10 mm or more, or 6 to 9 mm with a risk factor; ultrasound surveillance at 6, 12 and 24 months otherwise; no follow-up for polyps of 5 mm or less without risk factors (ESGAR, EAES, EFISDS and ESGE 2022). | Joint European polyp guideline (Eur Radiol 2022) | - |
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| All comers | Unresectable or metastatic disease, first line | Gemcitabine and cisplatin with durvalumab (TOPAZ-1, in which 25 percent of patients had gallbladder cancer; NICE TA944) or with pembrolizumab (KEYNOTE-966; not appraised by NICE), with molecular profiling including HER2 at diagnosis and biliary drainage first if jaundiced. Second-line, HER2-directed and other targeted options follow in the rows below. | NICE TA944 (2024) | 98 | |
| All comers | Locally advanced, unresectable, non-metastatic | Gemcitabine and cisplatin with durvalumab as for metastatic disease; consider chemoradiotherapy or stereotactic radiotherapy within a trial (UK ABC-07; India POLCAGB, RUGB) and reassess for conversion surgery. | NCCN · Category 2A (systemic therapy); radiotherap… | 94 | |
| HER2 | Newly diagnosed advanced disease: HER2 and genomic testing | HER2 testing (immunohistochemistry and in situ hybridisation) and a tumour gene panel at diagnosis of advanced disease: about one in ten gallbladder cancers is HER2-positive on staining and about one in seven carries a HER2 gene change, and zanidatamab is licensed (MHRA, February 2026) and NICE-recommended (TA1153, May 2026) for HER2-positive biliary cancer after chemotherapy; mismatch repair, BRAF V600E and NTRK results open tumour-agnostic options. On the NHS the hospital team requests the test through the Genomic Medicine Service on tissue already taken. | NCCN · Molecular testing recommended for all advan… | 91 |
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| All comers | Second line, no actionable target | FOLFOX with active symptom control (ABC-06, UK: overall survival 6.2 versus 5.3 months; gallbladder cancer eligible); liposomal irinotecan with fluorouracil is an NCCN option on NIFTY but was negative in NALIRICC and is not commissioned in the UK; trials preferred (SEVILLA ivonescimab versus FOLFOX at UCL; ComboMATCH for MAPK-mutant disease). | NCCN · Category 1 (FOLFOX) | 97 |
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| HER2 | HER2-positive (IHC 3+ or amplified), after first-line therapy | Zanidatamab (HERIZON-BTC-01: 41 percent response, 53 percent gallbladder cancer; FDA 2024, EU 2025, MHRA February 2026, NICE TA1153 May 2026) or trastuzumab deruxtecan for IHC 3+ (DESTINY-PanTumor02 biliary cohort 45 percent response; FDA tumour-agnostic 2024, not NICE-appraised); trastuzumab with pertuzumab through the UK DETERMINE platform; first-line zanidatamab within HERIZON-BTC-302 and SAFIR-ABC10. | NCCN · Category 2A | 97 |
| Subgroup | Setting | Approach | Products and trials | Guideline | Evidence |
|---|---|---|---|---|---|
| All comers | Suspected cancer in primary care | Urgent direct-access ultrasound for an upper abdominal mass consistent with an enlarged gallbladder (NICE NG12 1.2.10); urgent referral for jaundice; the UK pathway page carries the detail. | NICE NG12 (2015, updated) | 40 | |
| All comers | Tis or T1a found in the cholecystectomy specimen | No further surgery when the cystic duct margin is clear; the simple cholecystectomy is curative in almost all cases. | - | ||
| All comers | T1b, T2 or T3 (incidental or suspected before surgery) | Radical (extended) cholecystectomy: resection of the liver bed (wedge or segments IVb and V) with portal lymphadenectomy, bile duct resection only when the cystic duct margin is positive; re-resection 4 to 8 weeks after an incidental diagnosis; port sites not routinely excised. | AHPBA consensus statement (HPB 2015) | - | |
| All comers | After resection | Adjuvant capecitabine for six months (BILCAP, a UK trial in a mixed biliary population that required muscle-invasive gallbladder cancer for entry); the BILCAP record carries the figures, and the UK CAPBIL cohort saw no matched benefit, so ACTICCA-1 is awaited. | BILCAP (Lancet Oncol 2019) | 83 | |
| All comers | Jaundice from a blocked bile duct: stent or bypass | A stent placed by ERCP, or through the skin (PTC), is the usual way to relieve jaundice; metal stents stay open longer than plastic and are used when surgery to remove the cancer is not planned; a surgical bypass (joining the bile duct above the blockage to the small bowel) is reserved for people already having an operation or when a stent cannot be placed. Jaundice must be relieved before chemotherapy can be given safely. | Almadi 2017 meta-analyses (metal versus plastic stents); Cancer Research UK advanced gallbladder cancer | 40 | |
| All comers | A clinical trial or standard treatment | At every stage a trial can be a reasonable choice beside standard treatment: ask what the comparison arm is, whether a placebo is used (in KEYNOTE-966 the control arm had chemotherapy plus placebo, never placebo alone), what extra visits are involved, and that you can leave at any time. AMMF lists biliary trials open in the UK; HERIZON-BTC-302 is the first-line HER2 trial. | NHS: clinical trials; ESMO patient guide to biliary tract cancer | 95 | |
| All comers | Other actionable alterations (rare in gallbladder cancer) | BRAF V600E: dabrafenib with trametinib (ROAR biliary cohort 51 percent response; FDA tumour-agnostic 2022). Mismatch-repair deficiency or high tumour mutational burden: pembrolizumab (KEYNOTE-158). NTRK fusion: larotrectinib or entrectinib. KRAS G12C: sotorasib or adagrasib off-label or in trials. FGFR2 fusions (pemigatinib, futibatinib) and IDH1 mutations (ivosidenib) are intrahepatic features; the licences and NICE appraisals (TA722, TA1005, TA948) cover cholangiocarcinoma and the trials enrolled almost no gallbladder cancer. | NCCN · Category 2A (tumour-agnostic) | 98 | |
| All comers | Palliation of obstruction and symptoms | Biliary drainage by ERCP metal stent, percutaneous transhepatic drainage for hilar block or failed ERCP, or EUS-guided drainage (non-inferior to ERCP with fewer complications in a 125-patient randomised trial); duodenal stent or gastrojejunostomy for gastric outlet obstruction by expected survival (SUSTENT); opioids with coeliac plexus block for visceral pain; paracentesis or tunnelled catheter for ascites; early integrated palliative care. | NCCN · Category 2A | 87 |
Lines and subgroups are parsed from the setting text of each standard-of-care row and can misclassify an unusual phrasing; the row’s own setting is always shown. Guideline chips reflect the NCCN category and ESMO-MCBS grade recorded on the cancer page, checked on its stated date. Not medical advice.