Taking the right foods and supplements as part of the diet including omega-3 fatty acids, specific oral nutrition supplements, vegetables and fruits, folate, insoluble fiber, Vitamin C, natural salicylates, allium vegetables, seaweed, kelp and drinking coffee may help reduce the risk of cholangiocarcinoma/bile duct cancer or may improve cancer related cachexia and other signs and symptoms in cholangiocarcinoma patients. However, consuming alcohol and smoking, family history of cancer, obesity, consumption of raw cyprinoid fish, consumption of high nitrate foods, consumption of preserved vegetables and salted meats and a specific worm treatment may increase the risk of bile duct cancer. Additionally, taking Vitamin D3 along with certain chemotherapies may increase the treatment-induced toxicity in cholangiocarcinoma patients. Hence, it is really important to personalize nutrition to the specific cancer type and factors including lifestyle, body weight, food allergies, and ongoing treatments, to gain the benefits and stay safe.
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What is Cholangiocarcinoma or Bile Duct Cancer?
Bile duct cancer, also known as Cholangiocarcinoma, is a cancer that originates in the cells lining the bile ducts, which are small tubes that connect the liver to the small intestine. Bile ducts collect bile produced by the liver, drains it to gallbladder and finally into the small intestine, where it helps digest the fats in food.
Bile duct cancer/Cholangiocarcinoma is a rare form of cancer, with approximately 8000 new cases diagnosed in the United States each year, mostly in people over the age of 70. (American Cancer Society) The 5-year survival rate of cholangiocarcinoma ranges between 2-30%.
What are the Different Types of Cholangiocarcinoma?
Based on the location where this cancer may arise within the bile drainage system, cholangiocarcinoma is classified into two:
- Intrahepatic bile duct cancer – which affects the bile ducts located within the liver
- Extrahepatic bile duct cancer – which occurs in the bile ducts outside the liver.
Intrahepatic cholangiocarcinoma is usually associated with a worse prognosis compared to extrahepatic cholangiocarcinoma.
Extrahepatic bile duct cancers are further classified into the following types.
- Extrahepatic perihilar bile duct cancer – which occurs just outside of the liver and is located at the notch of the liver where the bile ducts exit
- Distal extrahepatic bile duct cancer – which occurs outside of the liver near to the bowel, where the bile ducts enter the intestine called the ampulla of Vater
What are the Signs and Symptoms of Bile Duct Cancer or Cholangiocarcinoma?
The signs and symptoms seen in a patient with bile duct cancer can vary based on the location of the cancer. During initial stages, the bile duct cancer patients may not show any signs and symptoms. Cholangiocarcinoma usually starts showing symptoms only when the bile ducts begin to get obstructed, in a more advanced stage, due to which patients usually present more developed cancers during diagnosis.
Some of the signs and symptoms of cholangiocarcinoma or bile duct cancer include:
- Jaundice – Yellowing of whites of the eyes and skin
- Itchy skin
- Darker urine and paler stools
- Unintended weight loss
- Fatigue and general weakness
- High fever and chills
- Abdominal pain
- Feeling sick
What are the Treatments for Bile Duct Cancer or Cholangiocarcinoma?
The stage of bile duct cancer depends on various factors such as location of the cancer in the bile ducts, size of the tumor and the extent of spread/metastasis.
Treatment for bile duct cancer depends upon the stage of the cancer, where the cancer is located, the general health of the patient and whether it could be removed completely by surgery. Apart from surgery, chemotherapy and radiotherapy are other treatment regimens used for bile duct cancer. Other treatments such as palliative treatment are mainly not aimed at treating the cancer, but for improving the quality of life. Photodynamic treatment is also used to shrink the tumor and control the symptoms of cholangiocarcinoma/bile duct cancer.
What is the Role of Diet/Foods in Bile Duct Cancer?
Researchers across the world have carried out different studies to evaluate the impact of the intake of different foods and diet in bile duct cancer patients as well as the association of various foods with the risk of bile duct cancer. Based on few preclinical, observational and clinical studies, here are the examples of some foods which have been shown to be good or bad, when it comes to bile duct cancer.
Studies associated with the Impact of Different Foods/Diet in Bile Duct Cancer Patients
Omega-3 Fatty Acid Use in Bile Duct Cancer Patients Undergoing Chemotherapy may be beneficial
Researchers from the Jikei University School of Medicine in Japan evaluated data from 27 pancreatic and bile duct cancer patients who underwent chemotherapy between November 2014 and November 2016 and were given an enteral (intake of food via the gastrointestinal tract) nutrient based on omega-3 fatty acids and found that in all 27 patients, the skeletal muscle mass had significantly increased post the initiation of omega-3-fatty acids as compared to that before the supplementation of this nutrient. (Kyohei Abe et al, Anticancer Res., 2018)
Hence, including omega-3 fatty acid as part of the bile duct cancer patient’s diet may be beneficial in improving cancer related weakness or cachexia.
Oral Nutrition Supplements (ONS) Use in Bile Duct Cancer Patients Undergoing Chemo may be beneficial
In a clinical study done by the researchers from the Yonsei University in Seoul, Korea, they evaluated the effects of oral nutrition supplements (ONS) on pancreatic and bile duct cancer/cholangiocarcinoma patients undergoing chemotherapy and found that ONS might improve nutritional status of these patients by increasing body weight, fat-free mass, skeletal muscle mass, body cell mass, and fat mass, especially in those undergoing the first cycle of chemotherapy, and may reduce fatigue symptoms. (Seong Hyeon Kim et al, Nutrients., 2019)
Co-Use of Vitamin D3 and certain Chemotherapies may Increase Chemo-induced Toxicity in Cholangiocarcinoma Patients
In a study done by the researchers from the Khon Kaen University in Thailand, the researchers evaluated the toxicity and tolerability of intermittent-high dose CAL -active form of Vitamin D3 in advanced inoperable intrahepatic cholangiocarcinoma (CCA) patients and the therapeutic efficacy of combinations of Vitamin D3 and 5-FU-based chemotherapeutic drugs. The study found that Vitamin D3 appeared to be safe and tolerated well in advanced intrahepatic cholangiocarcinoma patients, however, the co-administration of Vitamin D3 along with 5-FU-based chemo drugs augmented the drug toxicity. (Aumkhae Sookprasert et al, Asian Pac J Cancer Prev., 2012)
Studies associated with Different Foods/Diet/Life-Style and the Risk of Bile Duct Cancer
Intake of Vegetables/Fruits, Folate, Insoluble fiber and Vitamin C may Reduce the Risk of Extrahepatic Bile Duct Cancer
In a population-based prospective cohort study in Japan involving 80,371 people aged 45 to 74 years, the researchers from the Osaka University, Graduate School of Sagami Women’s University and National Cancer Center in Japan evaluated the association of vegetable/fruit intake with the risks of gallbladder cancer, intrahepatic bile duct cancer and extrahepatic bile duct cancer. During the follow up period, 133 gallbladder cancer, 99 intrahepatic bile duct cancer and 161 extrahepatic bile duct cancer cases were reported. (Takeshi Makiuchi et al, Int J Cancer., 2017)
The study found that compared to those with least consumption of vegetable and fruits, people with highest consumption had a 51% reduced risk of extrahepatic bile duct cancer. Additionally, the study also found a reduced risk of extrahepatic cholangiocarcinoma with folate, insoluble fiber and Vitamin C intake, however these protective effects were not seen in gallbladder and intrahepatic bile duct cancers.
Taking Allium Vegetables, Seaweed and Kelp may Reduce, and Preserved vegetables and salted meats may Increase Bile Duct Cancer Risk
Evaluation of data from a population-based case-control study in Shanghai, China by the National Cancer Institute,in Maryland, United States and other institutes in the US and China, found that intake of allium vegetables such as onions, garlic and shallots, seaweed and kelp may reduce the risk of biliary tract cancers such as gallbladder cancer, extrahepatic cholangiocarcinoma and ampulla of Vater cancers. However, the study also found that the intake of preserved vegetables and salted meats may increase the risk of these cancers. (Shakira M Nelson et al, PLoS One., 2017)
Tea Consumption may Reduce the Risk of Cholangiocarcinoma
Researchers from the Chinese Academy of Medical Sciences and Peking Union Medical College, The First Affiliated Hospital of China Medical University, and University of Macau in China carried out a meta-analysis of published observational studies obtained through literature search in PubMed, EMBASE, and ISI Web of Science published before October 2016 to evaluate the association between tea consumption and the risk of biliary tract cancer (which also includes cholangiocarcinoma). The study found that compared to those who do not drink tea, the incidence of biliary tract cancer significantly reduced by about 34% in those who consumed tea, with the effect more prominent in women. (Jianping Xiong et al, Oncotarget., 2017)
Coffee Consumption may not be associated with the Risk of Biliary Tract Cancers
Researchers from different Universities in Italy, Poland and the United Kingdom evaluated the association between coffee intake and biliary tract cancer (which includes cholangiocarcinoma or bile duct cancer) and liver cancer risk, based on 5 studies on Biliary tract cancer and 13 studies on Liver cancer, obtained through literature search in the PubMed and EMBASE databases till March 2017. (Justyna Godos et al, Nutrients., 2017)
The study found that an increased coffee consumption may not be associated with biliary tract cancers including cholangiocarcinoma, however, there was decreased risk of liver cancer with high intake of coffee.
Green Tea Intake May Reduce the Risk of Biliary Tract Cancers
In a population-based prospective cohort study in Japan, the researchers from the Osaka University, Sagami Women’s University and the National Cancer Center, Japan evaluated the association of green tea (total green tea, Sencha, and Bancha/Genmaicha) and coffee consumption with the risk for biliary tract cancers. The study found that a high green tea consumption may be associated with a reduced risk of biliary tract cancer, with the effect more prominent in Sencha consumption. (Takeshi Makiuchi et al, Cancer Sci., 2016)
Consuming Raw Fish Dishes Related to Liver Fluke (Parasitic Worm) Infection may Increase the Risk of Cholangiocarcinoma
A cross-sectional descriptive study conducted by the researchers from the Suranaree University in Thailand evaluated raw fish consuming behavior related to liver fluke (parasitic worm) infection among the population at risk for opisthorchiasis (a parasitic disease caused by species in the genus Opisthorchis) and cholangiocarcinoma in Nakhon Ratchasima Province, Thailand. The study used dietary questionnaire based data from those at very high risk of cholangiocarcinoma and found that 78% of these participants had a past history of raw fish consumption. The study found that several dishes related to liver fluke infection were consumed by those at high risk of cholangiocarcinoma, mainly raw fermented fish, under smoked catfish, raw pickled fish, and raw spicy minced fish salad. (Wasugree Chavengkun et al, Asian Pac J Cancer Prev., 2016)
Smoking may Increase the Risk of Cholangiocarcinoma
A systematic review of 26 prospective studies with 1391 gallbladder, 758 intrahepatic bile duct, 1208 extrahepatic bile duct, and 623 ampulla of Vater cancer cases reported during the followup period found that those who were ever, former, and current smokers were associated with an increased risk of extrahepatic bile duct and ampulla of Vater cancers. The study also found that compared to those who never smoked, people who smoked >40 cigarettes per day were associated with an increased risk of Intrahepatic Cholangiocarcinoma. (Emma E McGee et al, J Natl Cancer Inst., 2019)
Another previous study done by the researchers from the Zhejiang University in China found that smoking, but not alcohol may be associated with an increased risk of extrahepatic cholangiocarcinoma. (Xiao-Hua Ye et al, World J Gastroenterol., 2013)
Intake of Raw Cyprinoid Fish, High Nitrate Foods, Liquor, and a Specific Anti-worm Medication may Increase Cholangiocarcinoma Risk
A meta-analysis done by the researchers from the Khon Kaen University in Thailand evaluated the risk factors for cholangiocarcinoma in Thailand based on studies obtained from online databases such as SCOPUS, Pro Quest, Science Direct, PubMed, and online public access catalog of Khon Kaen University since 2016. The study found a significant association between cholangiocarcinoma and factors such as age, Opisthorchis viverrini infection (a parasitic disease caused by species in the genus Opisthorchis), eating raw cyprinoid fish, family history of cancer, liquor consumption, and taking a specific anti-worm medication. (Siriporn Kamsa-ard et al, Asian Pac J Cancer Prev., 2018)
In another systematic review done by the researchers from the Tufts University in United States and other Institutions in Canada, China and Italy, they highlighted that in addition to Opisthorchis viverrini/liver fluke, alcohol and smoking, family history of cancer, consumption of raw cyprinoid fish, consumption of high nitrate foods, and a specific worm treatment are also associated with a significantly increased risk of bile duct cancer. (Jennifer A Steele et al, Infect Dis Poverty., 2018)
Fermented Food Intake can Worsen Risk Factors of Cholangiocarcinoma-associated Opisthorchiasis (parasitic disease) – Preclinical Study
A preclinical study done by the researchers from the Rajamangala University of Technology ISAN and Khon Kaen University in Thailand found that consumption of fermented foods such as pla som-fish fermented for 1 day, som wua-fermented beef, som phag-fermented vegetables, and pla ra-fish fermented for 6 months can exacerbate cholangitis and cholangiofibrosis, which are the key risk factors for cholangiocarcinoma-associated opisthorchiasis (a parasitic disease). (Pranee Sriraj et al, Parasitol Res., 2016)
Natural Salicylate containing Foods may Reduce the Risk of Cholangiocarcinoma
Researchers from the Chinese Academy of Medical Sciences and Peking Union Medical College (CAMS & PUMC), China, conducted a systematic review and meta-analysis of studies obtained through literature search in PubMed, EMBASE, and ISI Web of Science till October 2017,involving 12,535 cholangiocarcinoma cases and 92,97,450 healthy controls and found that salicylate/aspirin administration may reduce the risk of cholangiocarcinoma by 31%, particularly in the intrahepatic cholangiocarcinoma. (Jianping Xiong et al, Cancer Manag Res., 2018)
Hence, a diet including foods containing natural salicylate such as apricots, broccoli, thyme and rosemary may possibly be beneficial for reducing the risk of cholangiocarcinoma.
Overweight and Obesity may Increase the Risk of Cholangiocarcinoma
A meta-analysis done by the researchers from the Jiangxi Science and Technology Normal University and Huazhong University of Science and Technology, China based on 14 prospective cohort studies and 15 case-control studies involving 11,448,397 participants (6,733 patients with gallbladder cancer [GBC] and 5,798 patients with extrahepatic bile duct cancer [EBDC]/Cholangiocarcinoma) found that excess body weight (Obesity/Overweight) may be associated with a significantly increased risk of extrahepatic bile duct cancer. (Liqing Li et al, Obesity (Silver Spring)., 2016)
In another pan-European study involving 467,336 men and women, the researchers found that a high physical activity may be associated with a reduced risk of developing liver cancers. However, they didn’t find any significant association between physical activity and cholangiocarcinoma risk (Sebastian E Baumeister et al, J Hepatol., 2019)
Consumption of Soft Drinks and Juices may not be associated with the Risk of Biliary Tract Cancers/Cholangiocarcinoma
A European Prospective Investigation into Cancer and Nutrition Cohort study assessed the associations between intake of soft drinks (sugar sweetened/artificially sweetened) and fruit and vegetable juices and the risk of liver carcinoma, intrahepatic bile duct/cholangiocarcinoma and biliary tract cancers using data from 477,206 participants from 10 European countries. The study found no significant association between soft drink intake and the risk of intrahepatic bile duct/cholangiocarcinoma. (Magdalena Stepien et al, Eur J Nutr., 2016)
Zinc Intake may not Reduce the Risk of Cholangiocarcinoma
A case control study of the European Prospective Investigation into Cancer and Nutrition cohort also found that increased Zinc levels may be associated with a decreased risk of developing liver cancer, but found no association with cholangiocarcinoma. (Stepien M wt al, Br J Cancer, 2017)
Different studies suggested that intake of omega-3 fatty acids, oral nutrition supplements, vegetables and fruits, folate, insoluble fiber and vitamin C, natural salicylates, allium vegetables, seaweed, kelp and drinking coffee as part of the diet may help reduce the risk of bile duct cancer/cholangiocarcinoma or may improve cancer related cachexia in cholangiocarcinoma patients. However, obesity, consuming alcohol and smoking, family history of cancer, consumption of raw cyprinoid fish, high nitrate foods, preserved vegetables and salted meats, and a specific worm treatment may increase the risk of bile duct cancer. Following anti-inflammatory diet including fruits and vegetables, maintaining a healthy weight, adopting a physically active lifestyle and doing regular exercises are necessary to stay away from bile duct cancer.
Cancer patients often have to deal with different chemotherapy side effects which affect their quality of life and look out for alternative therapies for cancer. Taking the right nutrition and supplements based on scientific considerations (avoiding guesswork and random selection) is the best natural remedy for cancer and treatment related side-effects.