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Most stage 0, I, and II cancers and possibly some stage III cancers may be resectable. This means it might be possible to remove them completely with surgery. But other factors can impact whether this is a good option, such as the location of the cancer and whether you are healthy enough to have major surgery.

Surgery to remove the cancer completely is the preferred treatment if it's possible. If surgery may be an option, 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 it 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.

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

In cases where doctors don’t know if a cancer is resectable, chemotherapy and/or radiation therapy may be used first. These treatments 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 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 perihilar bile duct cancers, and for certain small intrahepatic bile duct cancers, a liver transplant may be an option. This involves the complete removal of the liver and bile ducts and replacement with a healthy liver. Chemo and radiation are typically given first to shrink the tumor and help confirm the cancer hasn't spread before transplant.

It's often hard to find a compatible liver donor, and not everyone qualifies. But in carefully selected people treated under a strict protocol, liver transplant can offer good long-term outcomes and a chance for a cure. Cancer recurrence after transplant remains a real risk, which is why patient selection is so important.

Radiation, chemotherapy, and immunotherapy

For most bile duct cancers, it’s clear from imaging tests and/or laparoscopy when they're not resectable. For these cancers, treatment tries 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 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 changes (mutations), targeted therapy drugs might be an option. These drugs work by attacking proteins that help cancer cells grow. They can help block the growth or spread of cancer. Your doctor might test your tumor for gene changes. They might also test your blood for bits of tumor DNA, called circulating tumor DNA. This is sometimes called a liquid biopsy. These tests can show if a targeted drug could help.

Ablation

For bile duct cancers within the liver, ablation using extreme heat (radiofrequency ablation), cold (cryotherapy), or alcohol (alcohol ablation) might help control the tumors. But almost all 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 you may be able to get new treatments that aren’t yet widely available. But these new treatments may or may not work better than current treatments, which is what clinical trials are done to find out. Taking part in a clinical trial can also help improve treatments for people in the future.

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.

This care includes medications to prevent nausea, control pain, and maintain 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. 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.

Cancer is called recurrent when it comes back after treatment. Recurrence is called local when it happens in the same place it started. Or it can be regional when it comes back near the place it started. Or recurrence can be distant when it happens 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 your 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.

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.