“Our patients deserve better”—roadblocks to optimal care in biliary malignancies

Biliary tract cancers (BTCs) are associated with poor outcomes, with many patients never receiving any cancer-directed treatment. Population-based registries from England, France, Italy and Spain share a similar picture: emergency presentation, rather than planned referral, accounts for roughly half of diagnoses, and >50% of patients with cholangiocarcinoma in England received neither surgery, systemic therapy nor stenting. This attrition is not exclusive to real-world settings: in PROOF-301 and FIGHT-302, a considerable proportion of eligible or randomly assigned patients never started their allocated treatment. BTC is also no longer a disease confined to older adults, with ∼7% of cases diagnosed in individuals <50 years of age. On top of this, access to reimbursed therapies, molecular profiling and expert multidisciplinary discussion remains markedly uneven across Europe. "Our patients deserve better" and closing these gaps in diagnosis, access to treatment and care delivery is as urgent as developing new drugs for this disease.