Systematic review with network meta‐analysis: adjuvant therapy for resected biliary tract cancer

Summary Background Major adjuvant therapies for biliary tract cancer (BTC) include fluorouracil, gemcitabine and chemoradiation (CRT), but the optimum regimen remains inconclusive. Aim To compare these therapies in terms of patient survival rates after resection and toxic effects. Methods We searched PubMed for controlled trials comparing the above three therapies with each other or observation alone until 31 January 2014. We estimated the hazard ratios (HRs) for death and odds ratios (ORs) for toxic effects among different therapies. Subgroup analyses based on positive lymph node or resection margin were also performed. Results Twelve eligible articles were included. Gemcitabine improved 5‐year survival (HR 2.12, 95% CI, confidence interval 1.23–4.02, P = 0.01), whereas fluorouracil (HR 1.61, 95% CI 0.74–3.67) and CRT (HR 1.55, 95% CI 0.82–3.32) provided a poorer survival outcome compared with gemcitabine after 1 year. Similarly, for 5‐year survival rates, although differing, CRT did not provide a significant improvement in survival (HR 0.46, 95% CI 0.20–0.97) compared with gemcitabine. Fluorouracil did not appear to provide benefit over gemcitabine (HR 1.56, 95% CI 0.77–3.35). CRT was ranked highest for toxic effects including haematological (OR 5.45, 95% CI 0.01–483.85) and nonhaematological (OR 5.77, 95% CI 0.01–3807.40). Conclusions Chemotherapy with gemcitabine is the optimum adjuvant treatment with a balanced benefit‐toxicity ratio for resected biliary tract cancer. Chemoradiation was more likely to cause toxic effects.