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, grew up watching Star Wars. But unlike other fans, his favorite character wasn¡¯t Luke Skywalker or Han Solo. Instead, Ludmir favored a character who got much less screen time: the man tasked with controlling the Death Star¡¯s laser beams.

Today, Ludmir¡¯s work as a radiation oncologist in Gastrointestinal Radiation Oncology has certain similarities to the movies he grew up watching. But instead of using lasers to help the Empire, Ludmir uses radiation to help treat patients facing cancers in the biliary tract, such as bile duct and gallbladder cancer.

Now, Ludmir is sharing how radiation therapy is used to treat biliary cancer ¨C and how the field is advancing.

What radiation therapy options are available to bile duct and gallbladder cancer patients?

Biliary cancers are relatively uncommon diseases that can occur in the bile ducts within or outside of the liver, as well as in the gallbladder. Radiation therapy for biliary cancer may be given after surgery to control a tumor from spreading or instead of surgery to provide relief from symptoms.

Common radiation approaches for biliary cancer treatment include intensity modulated radiation therapy (IMRT) or stereotactic body radiation therapy (SBRT). These photon-based approaches use image guidance to send high dose radiation directly to the tumor.

While the words ¡°high-dose radiation¡± may give a patient pause at first mention, research shows dose-escalated radiation can improve tumor control and survival among biliary cancer patients while limiting side effects and damage to surrounding organs such as the liver, stomach and small bowel.

¡°Data from MD Anderson has demonstrated that if you can safely turn up the dial with radiation, you are more likely to control and kill off these tumors,¡± Ludmir says.

Proton therapy, which utilizes larger radiation particles and has different dose distribution properties compared to photon-based approaches, may also be used to treat biliary cancers.

Oncologists decide which type of radiation to use on a case-by-case basis that considers each patient¡¯s anatomy, liver function and tumor location.

¡°These different radiation options are part of a toolbox of techniques. No one technique is the right choice 100% of the time, so we pick the technique that works best for each patient,¡± Ludmir says.

What are the challenges of using radiation therapy for biliary cancer?

The bile ducts are located in what Ludmir calls ¡°prime real estate¡± near the gallbladder, liver, stomach and small bowel. Because even small movements from breathing and digestion can alter the position of the bile ducts, special techniques and technologies are used to make sure radiation is delivered precisely to the tumor site while avoiding unnecessary exposure to these neighboring organs, which could lead to damage or side effects.

Prior to treatment, patients learn how to hold their breath during radiation and are instructed to limit what they eat and drink to minimize gas bubbles in the stomach. In some cases, spacers are surgically inserted to protect parts of the body from radiation.

During treatment, radiologists use an array of image guidance technologies to accurately target tumors and avoid critical structures.

¡°It¡¯s a testament to expertise and technological advances that we can treat these tumors while paying attention to how patients are breathing, ensuring we're treating exactly where we want to be and not where we don¡¯t,¡± Ludmir says.

What is the process for receiving radiation therapy for bile duct and gallbladder cancers?

Radiation treatment can last anywhere from a week to multiple weeks with individual appointments lasting about an hour. Patients lie in a bean-bag-like-device molded to the shape of their body, while a pre-treatment CT scan ensures proper alignment. Aside from an intercom message announcing the radiation has begun and for the patient to hold their breath, a patient may not even notice the process is underway. Twenty minutes later, the process is complete.

¡°Folks often walk out of the room after the first day of treatment and say, ¡®Oh, that was not nearly as bad as I thought it would be,¡¯¡± Ludmir says. ¡°It¡¯s a misconception people have that radiation is painful.¡±

What¡¯s next in the field of radiation therapy for biliary cancer?

New advances in radiation therapy for biliary cancers include everything from the types of subatomic particles to the machines used to deliver radiation. New forms of radiation are being explored in clinical trials, dose-escalation continues to advance, and equipment continues to improve.

¡°Advances in technology, which are often behind the curtain, are really what have allowed us to do things that weren¡¯t possible before,¡± Ludmir says. ¡°As much as technology has changed over the last five years, we anticipate even further advances in the coming five years.¡±

With these advances come better and better patient outcomes. And, for Ludmir, a job even more gratifying than anything depicted on screen.

¡°There's really nothing like seeing patients come back months and years after treatment, and they're doing well. The end result is satisfying beyond words.¡±

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For over two years, JoAnne Holly fought a terrible rash on her face and back. She visited several doctors and even had biopsies done. They all came back inconclusive.

But on Dec. 23, 2019, the rash became so bad that JoAnne visited her doctor, determined to find the root of the issue. Her doctor ordered extensive blood work, which showed her liver enzyme levels were extremely high. Because of the holiday, JoAnne¡¯s results were delayed, and she didn¡¯t get an ultrasound until January.

¡°My doctor called me at work the next day telling me to I needed to get my results in person ¨C and to bring my husband, Mark,¡± JoAnne recalls. ¡°I knew something was wrong. But never in a million years could I have imagined what was coming from just a skin rash.¡±

Choosing MD Anderson for treatment

Based on the ultrasound, JoAnne¡¯s doctor said it appeared she had pancreatic cancer with metastases to the liver. Two areas on the pancreas had lesions.

¡°She was crying giving me the news,¡± says JoAnne, who was 53 at the time. ¡°She told me, ¡®You need to get everything in your world together because your life is about to get crazy, fast.¡¯ This news was devastating.¡±

JoAnne had a CT scan at a local hospital the next day. It showed that her pancreas was completely clean. But there was evidence of large tumors on the left side of her liver.

JoAnne lived in Huntsville, Texas, just about an hour north of Houston. She knew of MD Anderson¡¯s reputation for cancer care. So, when she found out she had cancer, there was only one place she wanted to go.

¡°MD Anderson is the best in the world,¡± she says. ¡°I can¡¯t imagine being anywhere but MD Anderson.¡±

A bile duct cancer diagnosis

JoAnne came to MD Anderson in February 2020. Additional testing and pathology confirmed her diagnosis: stage IIIB intrahepatic cholangiocarcinoma, a type of cancer that starts in the bile ducts inside the liver.

She met with her care team, which included gastrointestinal medical oncologist , and hepato-pancreato-biliary surgical oncologist They immediately went to work developing a personalized treatment plan combining chemotherapy and surgery.

Research from clinical trials influences bile duct cancer treatment???

At that point, doctors advised against surgery. This was because JoAnne¡¯s tumor was large and had spread to her lymph nodes. If she had surgery upfront, there was an extremely high risk that the cancer would come back in less than one year.

¡°Dr. Lee recommended I enroll in a clinical trial,¡± says JoAnne. ¡°I was on board.¡±

But because there were cancer cells in the lymph nodes under her chest wall, she didn¡¯t qualify.

This didn¡¯t deter her care team. The chemotherapy drugs gemcitabine and cisplatin are commonly used to treat bile duct cancer. Previous clinical trials had shown significant tumor shrinkage when the chemotherapy drug nab-paclitaxel, which is typically used to treat pancreatic cancer, was added to this combination. So, JoAnne¡¯s doctors developed a treatment protocol based on this combination.

She had nine cycles of the aggressive chemo regimen at MD Anderson The Woodlands, close to her home. The goal was to shrink her tumors and lymph nodes enough so she could have surgery and reduce the chance of recurrence.

¡°Halfway through treatment, I had a CT scan, and my tumors had shrunk by 20% to 25%,¡± JoAnne says.

When she had her next CT scan, most of the tumors had shrunk by 50%. This meant she could schedule surgery.

Successful bile duct cancer surgery

On Aug. 13, 2020, Tzeng performed the six-hour surgery to remove half of JoAnne¡¯s liver (left and central).

After she recovered from surgery, JoAnne had five more cycles of chemo. Due to her low platelet count, doctors reduced the chemo strength by 40%, and the first two treatments did not include nab-paclitaxel.

One month later, at her first scan after surgery, her liver had already regenerated.

¡°I¡¯ll never forget seeing Dr. Tzeng the morning after my surgery,¡± she says. ¡°He was so jubilant. He said he¡¯d come straight from pathology to tell me all of my margins came back clean on all of my lymph nodes. And my liver and kidneys were functioning at 100%. It was a miracle.¡±

MD Anderson treats complications after surgery

JoAnne didn¡¯t experience any nausea during treatment. This surprised her nurses, given the strong chemo she was taking.

¡°I took nausea medicine the first round to get ahead of things, but I never took it again,¡± she says. ¡°There were times my bones ached, and I had some insomnia. But no nausea.¡±

JoAnne did have a significant chyle leak a few weeks after her surgery. This rare but expected condition is caused by a major disruption in the lymphatic chain in any part of the body. It usually occurs in the abdomen from aggressive removal of lymph nodes.

¡°Everything just gets kind of confused,¡± she says. ¡°Instead of the chyle collecting and being transported and absorbed by the intestine out of your body, it collects and pools, causing a water-like sac of fluid. The pain from the pressure was excruciating.¡±

JoAnne spent almost a week at MD Anderson, where her care team drained two liters of fluid that had collected in her chest and upper abdomen.

¡°Once drained, my pain greatly decreased,¡± she says.

Grateful for support and MD Anderson

While undergoing treatment, JoAnne received support from far and wide. This included her family, friends, church members and people she knew from high school and college.

¡°People everywhere were praying for me, and my small group at church rallied around me,¡± she says. ¡°My two kids were great, and I have the best husband in the world.¡±

JoAnne and her family are fairly private people, but they want to use her story to help more people facing cancer. She encourages everyone to advocate for themselves when something in their body doesn¡¯t quite feel right.

¡°I¡¯m so grateful for MD Anderson. I trust my doctors completely,¡± says JoAnne. ¡°Dr. Tzeng gave me such assurance and confidence from day one that he could take care of the cancer. He just needed me to fight. I give God all the credit ¨C He provided everything else through MD Anderson.¡±

JoAnne received her first no evidence of disease (NED) on Oct. 12, 2020. She returns to MD Anderson every six months for scans. After five years, she¡¯ll come only once a year.

¡°MD Anderson is the only place I¡¯m going,¡± says JoAnne. ¡°They¡¯ve taken such great care of me. There¡¯s no way I could ever consider going anywhere else.¡±

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Cancer is not uncommon in my family, but I was still totally unprepared for my own diagnosis.

In June 2015, I was a healthy 43-year-old mom and first-grade teacher who never got sick. Then I noticed a pain in my left arm while I was packing up my classroom. It had been bothering me for a couple of weeks, but I hadn¡¯t given it much thought. I nursed it for another month before finally going to the doctor. She said I¡¯d probably pulled a muscle moving boxes, but I pressed for a scan. Moving my arm was painful enough that I was sure something needed to be done. And I wanted to get it taken care of while I was still on summer break.

The following week I had an MRI. I was pretty convinced I¡¯d torn my rotator cuff, so I wasn¡¯t worried when the doctor asked me to come back for the results later that same day. I expected her to tell me I needed surgery. And she did ¡ª but not for the reason I thought. Instead, she said there was a mass growing in my humerus. The tumor was so large it had split the bone. The radiologist suspected it was cancer.

Why I chose MD Anderson for my bile duct cancer treatment

After that, I just went numb. I didn¡¯t hear anything else, except, ¡°Do you have an oncologist?¡± And I remember thinking, ¡°Huh? Do healthy people really have an oncologist on stand-by?¡± Then I burst into tears.

After I calmed down, I said I wanted to go to MD Anderson. My mom has been treated there for years, so I knew it provided the best level of care, and I wasn¡¯t going to settle for less. ?

Worst birthday present ever: a cancer diagnosis

The following week, I met with MD Anderson surgeon . And after a whirlwind of tests, I got the official news: I had cancer. It was Aug. 5, 2015 ¡ª the day after my 44th birthday. At the time, I was already back in my classroom, getting ready for a new school year. But I needed surgery to remove the tumor immediately. The procedure was scheduled for the next day.

When the mass on my arm was biopsied, the results revealed just how rare my cancer was. It turns out I have something called cholangiocarcinoma, or intrahepatic bile duct cancer. There was a tumor about the size of a baseball in my liver. It had spread to my left arm and right rib, which made it stage IV.

Targeted therapy clinical trial is keeping my bile cancer in check

I had 15 rounds of radiation to kill the cancer before meeting with another MD Anderson doctor, Dr. Gauri Varadhachary, who specializes in cancers of the digestive system. We discussed additional treatment options. She recommended ¡°maintenance¡± chemotherapy to prevent a recurrence. I did that for six months, then took a year off to give my body a break.

When the cancer started growing again, she suggested I consider a new clinical trial. It explores whether a targeted therapy called ramucirumab can help control bile duct cancer. The goal is to keep my cancer stable and prevent it from spreading anywhere else.

I¡¯m willing to try anything that keeps me alive with a good quality of life, so I decided to do it. I got my first infusion of ramucirumab in September, and have had another one every two weeks since. My main tumor hasn¡¯t shrunk any, but it also hasn¡¯t grown. And stable is good. Particularly since it¡¯s allowed me to keep teaching first grade full time. I am so thankful for that!

I¡¯m still here ¡­ and still fighting

Over the past two years and six months, I¡¯ve had surgery, 15 rounds of radiation, 50+ rounds of chemotherapy and countless scans. I have gained weight, lost my hair, developed neuropathy and battled treatment-induced high blood pressure. But today, I am still living, still teaching, still making memories and still fighting cancer.

Some days are harder than others, but I try to live each one as if it were my last. I hate having cancer, but I am blessed to have my faith, my family and friends, and most of all, MD Anderson in my corner. Because of its doctors, nurses and entire staff, I¡¯ve lived longer than I ever imagined.

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