Treatment Options Based on the Extent of Bile Duct Cancer

The extent of bile duct cancer is an important factor in deciding on treatment options. Whenever possible, surgery is the main treatment for bile duct cancers. It offers the only realistic chance for a cure. Because of this, doctors generally divide bile duct cancers into:

• Resectable cancers, those that doctors believe can be removed completely by surgery, based on the results of imaging tests and other tests.
• Unresectable cancers, those that have spread too far or are in too difficult a place to be removed entirely by surgery.

Most bile duct cancers are unresectable by the time they're found.

Resectable bile duct cancers

Most stage 0, I, and II cancers and possibly some stage III cancers are potentially resectable (meaning it might be possible to remove them completely with surgery). But other factors can impact whether or not this is a good option, such as is the location of the cancer and whether the patient is healthy enough to have major surgery.

Surgery to remove the cancer completely is the preferred treatment if it's possible. If surgery is being considered, a staging laparoscopy may be done first. This allows the doctor to look inside the abdomen (belly) for any spread of the cancer that could make it unresectable. (Laparoscopy is described in Tests for Bile Duct Cancer.)

Types of surgery

The type of surgery done to remove the cancer depends on the location and extent of the cancer. (See Surgery for bile duct cancer for more details.)

Other treatments that may be used with surgery

If a person has jaundice (yellowing of the skin and eyes) before surgery, a stent or catheter may be put in the bile duct first. This allows the bile to flow the way it should. It can help relieve symptoms over a few days and might help make a person healthy enough to have the operation.

Radiation therapy and/or chemotherapy (chemo) may be given after surgery to try to lower the risk that the cancer will come back. This is called adjuvant therapy.

If it's clear that some cancer was left behind, a second surgery to take out more tissue may also be an option in some cases.

Sometimes it isn’t clear from imaging or other tests whether the cancer can be removed completely. These cancers may be called borderline resectable tumors. Some doctors may recommend treatment with radiation and/or chemo before surgery to try to shrink the tumor. (This is called neoadjuvant treatment.) Then, if the cancer shrinks, surgery can be done to try to remove all of it.

Unresectable bile duct cancers

These cancers cannot be removed with surgery. This includes most stage III and IV cancers. It might also include earlier stage cancers if a person isn’t healthy enough for surgery.

Trying surgery

As noted above, in cases where it isn’t clear if a cancer is resectable, chemotherapy and/or radiation therapy may be used first to try to shrink the cancer and make it resectable. Surgery could then be done to try to remove the cancer.

In some cases, the doctor might think that a cancer is resectable, but once the operation starts it becomes clear that it can’t be removed completely. For example, the cancer might turn out to have spread farther than was seen on the imaging tests done before surgery.

It doesn't help to remove only part of the cancer, and surgery could still cause major side effects, so this part of the operation is stopped. But while the doctor can see the area, a biliary bypass may be done to relieve any bile duct blockage or to try to keep it from happening in the future. Putting stents in the bile ducts to keep them open may also be an option.

Liver transplant

For some unresectable intrahepatic or perihilar bile duct cancers, a liver transplant (complete removal of the liver and bile ducts and replacement with a healthy organ) may be an option. Chemo and radiation may be given first.

It's often hard to find a compatible liver donor, but a liver transplant can provide a chance for a cure. However, bile duct cancer tends to recur (come back) very quickly after transplantation. As a result, liver transplant is rarely used.

Other options

For most bile duct cancers, it’s clear from imaging tests and/or laparoscopy when they're not resectable. For these cancers, treatment is aimed at trying to control the growth of the cancer for as long as possible and to relieve any symptoms it's causing.

Radiation and/or chemo: Radiation therapy and/or chemo may shrink or slow the growth of the cancer for a time. When chemo is given alone (without radiation) the drugs cisplatin and gemcitabine are often used. When chemo is given with radiation, 5-FU is the drug most often used.

Chemo plus immunotherapy: For advanced bile duct cancers that can’t be removed completely, another option might be chemo (cisplatin and gemcitabine), plus the immunotherapy such as pembrolizumab (Keytruda) or Durvalumab (Imfinzi).

Targeted therapy: For advanced bile duct cancers that have specific gene mutations (gene changes), targeted therapy drugs might be an option.

Ablation: For bile duct cancers within the liver, ablation using extreme heat (radiofrequency ablation) or cold (cryotherapy) or alcohol (alcohol ablation) might help control the tumors. But almost all of these cancers will start to grow again in the future.

Clinical trials: For people who want to continue trying to treat the cancer, taking part in clinical trials of newer treatments may be an option. This way patients can get the best treatment available now and may also get treatments that are thought to be even better.

Much of the focus of treating people with unresectable cancers is on relieving symptoms from the cancer. Two of the most important problems are bile duct blockage (which can lead to jaundice, itching, and other symptoms) and pain.

Palliative care

Palliative care is supportive care. It's aimed at preventing and treating symptoms or problems caused by the cancer. Palliative care is used with every type of cancer treatment and at every stage of bile duct cancer. It includes things like medicines to prevent nausea, pain control, and maintaining the flow of bile where a tumor may block it. Palliative care is focused on helping you feel better. It is not used to treat the cancer.

Maintaining your quality of life is an important goal. Please don’t hesitate to discuss pain, other symptoms, or any quality-of-life concerns with your cancer care team.

See Palliative Therapy for Bile Duct Cancer for details on some of these treatments.

Recurrent bile duct cancer

Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in the same place it started), regional (near the place it started), or distant (in other parts of the body, like the lungs). If the cancer comes back, further treatment depends on where the cancer recurs, the kind of treatment used in the past, and the patient’s overall health.

In most cases if the cancer comes back after initial treatment, it will not be resectable. Treatment will be aimed at controlling the cancer growth and relieving symptoms, as described above for unresectable cancers and palliative care.

In rare cases, if the cancer comes back where it started, surgery to try to remove the cancer (and possibly adjuvant therapy afterwards) may be an option. Because most of these cancers are not curable, people might want to consider taking part in a clinical trial of newer treatments.