Whenever possible, surgery is the main treatment for bile duct cancers, as it offers the only reasonable chance for a cure. Whether or not the cancer is resectable (completely removable by surgery) is a major factor when looking at treatment options.

Resectable bile duct cancers

This includes most stage 0, I, and II cancers and possibly some stage III cancers, but it also depends on the location of the cancer and a person's overall health. Surgery to completely remove the cancer is the preferred treatment if it is possible. The type of operation will depend on the location and extent of the cancer. (See the "Surgery" section for more details.)

Adjuvant radiation therapy and/or chemotherapy may be given after surgery to try to lower the risk that the cancer will come back, although 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 completely removed (based on looking at the surgery specimen 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.

In cases where the resectability of the cancer is not clear to begin with, some doctors may advise neoadjuvant radiation and/or chemotherapy to try to shrink the tumor before attempting surgery, although there is no strong evidence that this is helpful.

Unresectable bile duct cancers

This includes most stage III and IV cancers, as well as some earlier stage cancers if a person is not healthy enough for surgery.

As noted above, if it's not 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 may 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 be much more extensive than was visible on imaging tests before surgery. At this point it would not usually be helpful to go through with such a major operation, but the surgeon may 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 duct to keep it open may also be an option during surgery.

For some unresectable intrahepatic or hilar bile duct cancers, a liver transplant (after complete removal of the liver and bile duct) may be an option. Unfortunately, it is often hard to find a compatible liver donor. If a donor can be found, a liver transplant may provide a chance for a cure.

For other bile duct cancers that are clearly not resectable (based on the results of imaging tests and/or laparoscopy), treatment is aimed at trying to control the growth of the cancer and to keep symptoms to a minimum for as long as possible.

Radiation therapy and/or chemotherapy may shrink or slow the growth of the cancer for a time. For bile duct cancers within the liver, ablation using extreme heat (radiofrequency ablation) or cold (cryotherapy) may help control the tumors. Unfortunately, almost all 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 above the liver (percutaneously) or using an endoscope 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 of 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-killing drugs as needed. Some patients may hesitate to use opioid drugs for fear of becoming addicted to them. Yet some of the most effective pain-killing drugs are opioids, and studies show that most patients are not at risk of becoming addicted to drugs prescribed for them to stop pain for medical conditions.

It is important to realize that 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

In most cases if the cancer comes back (recurs) after initial treatment, it will not be resectable. Treatment will be aimed at trying to control the cancer growth and relieve symptoms, as described above for unresectable cancers. In rare cases, if the cancer recurs in the area where it started, surgery to try to completely remove the cancer (and possibly adjuvant therapy) may be an option. Because the vast majority of these cancers are not curable, people may want to consider taking part in a clinical trial of newer treatments.