Treatment of Bile Duct Cancer Based on the Situation
The extent of a bile duct cancer is an important factor in determining treatment options. Whenever possible, surgery is the main treatment for bile duct cancers, as it offers the only realistic chance for a cure. Because of this, doctors generally divide bile duct cancers into 2 groups:
- Resectable cancers are those that doctors believe can be removed completely by surgery, based on the results of imaging tests and other tests.
- Unresectable cancers have spread too far or are in too difficult a place to be removed entirely by surgery.
Unfortunately, most bile duct cancers have spread too far to be resectable by the time they are found.
Resectable bile duct cancers
Most stage 0, I, and II cancers and possibly some stage III cancers in the TNM staging system are potentially resectable. But this also depends on other factors, such as the location of the cancer and if a person is healthy enough for major surgery.
Surgery to remove the cancer completely is the preferred treatment if it is possible. If surgery is being considered, a staging laparoscopy may be done first to look inside the abdomen for any spread of the cancer that could make it unresectable. This procedure is described in the section “ How is bile duct cancer diagnosed?”
The type of operation done to remove the cancer depends on the location and extent of the cancer. (See the “ Surgery for bile duct cancer” section for more details.) If the patient has jaundice before the surgery, a stent or catheter may be placed in the bile duct first to allow the bile to flow. This can help relieve symptoms over a few days and might help make a person healthy enough for the operation.
Adjuvant radiation therapy and/or chemotherapy (chemo) may be given after surgery to try to lower the risk that the cancer will come back, but doctors aren’t sure how helpful this is. Adjuvant therapy is more likely to be used if there’s a higher chance that the cancer wasn’t removed completely (based on looking at the tissue removed at surgery in the lab). If it is clear that some cancer was left behind at the primary site, a second surgery 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 are often called borderline resectable tumors. Some doctors may recommend neoadjuvant treatment with radiation and/or chemo before surgery to try to shrink the tumor. Then, if the cancer shrinks, surgery can be done to try to remove all of the cancer. Although this approach is helpful with some other types of cancer, there is no strong evidence that this helps patients with bile duct cancer live longer.
Unresectable bile duct cancers
This includes most stage III and IV cancers, as well as some earlier stage cancers if a person isn’t healthy enough for surgery. Most bile duct cancers are unresectable.
As noted above, in uncommon 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 completely.
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 may turn out to have spread farther than was visible on imaging tests before surgery. At this point it would not usually be helpful to remove only part of the cancer, and surgery could still cause major side effects, so this part of the operation is stopped. The surgeon may instead do a biliary bypass at this time to relieve any bile duct blockage or to try to prevent it from becoming a problem in the future. Placing stents in the bile ducts to keep them open may also be an option during surgery.
For some unresectable intrahepatic or perihilar bile duct cancers, a liver transplant (after complete removal of the liver and bile duct) may be an option. Chemo and radiation may be given first. Although, it is often hard to find a compatible liver donor, a liver transplant can provide a chance for a cure.
For most bile duct cancers, it’s clear from imaging tests and/or laparoscopy that they are 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 is causing.
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 (Gemzar) are often used. When chemo is given with radiation, the drug 5-FU is most often used. For bile duct cancers within the liver, ablation using extreme heat (radiofrequency ablation) or cold (cryotherapy) may help control the tumors. Unfortunately, almost all of these cancers begin to grow again eventually. For people looking to continue to try to treat the cancer, taking part in clinical trials of newer treatments may be an option.
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.
Bile duct blockage can be treated (and in some cases prevented) with surgery or other procedures. In most people with unresectable cancer, it’s probably best to avoid a major operation if it can be helped. A biliary bypass may be a good option if a patient is already having surgery and the cancer turns out to be unresectable. In other cases, a stent or catheter may be placed in the bile duct to keep it open or allow it to drain. This can be done by placing a needle through the skin over the liver (percutaneously) or using an endoscope (an instrument used to look inside the body) passed down the mouth. It can also be done surgically in some cases.
Other options to help keep the bile duct open include brachytherapy (placing a tube with radioactive pellets inside the bile duct for a short time) and photodynamic therapy (injecting a light-sensitive drug into the blood and then using an endoscope with a special light on the end inside the bile duct).
Advanced bile duct cancer may be painful, so it is important to tell your doctor about any pain right away so it can be managed effectively. Radiation therapy, alcohol injection, and ablation of tumors within the liver can be used to relieve pain in some cases. Doctors often prescribe opioid pain medicines (like morphine) as needed. Some people may worry about taking opioid drugs for fear of becoming addicted to them. Yet some of the most effective pain medicines are opioids, and studies show that most people are not at risk of becoming addicted to drugs prescribed for them to stop pain for medical conditions.
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.
Recurrent bile duct cancer
Cancer is called recurrent when it come backs after treatment. Recurrence can be local (in or near the same place it started) or distant (spread to organs such as the lungs). If the cancer comes back, further treatment depends on where the cancer recurs, what kind of treatment was previously used, and on the patient’s 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. In rare cases, if the cancer recurs in the area where it started, surgery to try to remove the cancer (and possibly adjuvant therapy) 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.
Last Medical Review: November 1, 2014 Last Revised: January 20, 2016