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Background: Cholangiocarcinoma is a rare cancer with typically poor overall survival. Previous reports of clinical outcomes are limited to single-institution or small cohort studies. Our objective was to examine surgical and medical outcomes for patients with cholangiocarcinoma using a population-based cancer registry. Methods: Patients with cholangiocarcinoma treated in Los Angeles County from 1988 to 2006 were identified using the Los Angeles County Cancer Surveillance Program. Patients were evaluated by standard clinical and pathologic factors, including race/ethnicity, extent of disease, and treatment received (surgery, radiation therapy, chemotherapy, and none). Overall survival differences between treatment arms were assessed by Kaplan-Meier method and significance determined using log-rank test. Cox proportional hazard modeling was used in multivariate analysis.Results: Of the 1040 patients with cholangiocarcinoma, 48% were male and 52% were female. The median age of patients was 69. The majority of the patients were white (47%), followed by Hispanics (26%), Asians (18%), and blacks (9%). Most patients had distant disease (27%), whereas lower rates were observed for local (17%) and regional (17%) disease. There was no record of disease stage in 400 patients, but only 23 of these patients underwent surgical resection and 294 patients had no treatment. Curative-intent surgical resection was performed in 126 patients of the overall cohort. Of these, 80 patients had surgery alone, whereas 46 patients had combination therapy (surgery + chemotherapy, n=21; surgery + radiation, n=4; and surgery + chemotherapy + radiation, n=21). When comparing outcomes for treatment, overall survival was highest for the surgical arms (Table 1). On multivariate analysis, younger age, female gender, limited extent of disease, surgery, and chemotherapy were all associated with improved survival (Table 2).Conclusions: To our knowledge this is the largest report of clinical outcomes in patients with cholangiocarcinoma. Our results suggest that surgical resection remains the most important variable associated with improved survival. The role of chemotherapy and radiation with surgery is not clear but warrants further examination in the multidisciplinary management of this deadly cancer.
Table 1. Median survival in months based on treatment

Treatment Type	Median Overall Survival
No treatment	1.5
Chemotherapy only	7.5
Radiation only	5.5
Chemoradiation	7.5
Surgery Only	23.5
Surgery and radiation	23.5
Surgery and chemotherapy	17.5
Surgery, radiation and chemotherapy	21
Entire Cohort	4.5

Table 2. Univariate and Multivariate Analysis of Factors Predictive of Overall Survival

Factors	Univariate HR(95% CI)	Univariate p-value	Multivariate HR(95% CI)	Multivariate p-value
Age
<60	-	-	-	-
60-79	1.23 (1.05-1.43)	0.0086	1.18 (1.00-1.37)	0.0468
>=80	1.82 (1.51-2.18)	<0.0001	1.42 (1.16-1.74)	0.0007
Race/ethnicity
Caucasian	-	-	-	-
African American	1.38 (1.10-1.73)	0.0061	1.31 (1.04-1.65)	0.228
Asian	0.90 (0.75-1.08)	0.2439	0.10 (0.83-1.20)	0.9714
Hispanic	0.98 (0.84-1.14)	0.7789	0.95 (0.81-1.12)	0.5201
Unknown	0.80 (0.30-2.13	0.6471	1.53 (0.56-4.15)	0.4057
Extent of Disease
Local	-	-	-	-
Regional	1.19 (0.95-1.48)	0.1302	1.23 (0.98-1.54)	0.0701
Distant	1.89 (1.55-2.31)	<0.0001	1.74 (1.41-2.14)	<0.0001
Unknown	0.96 (0.85-1.09)	0.0005	1.02 (0.84-1.24)	0.8397
Sex
Male	-	-	-	-
Female	0.96 (0.85-1.09)	0.5686	0.86 (0.76-0.98)	0.0242
Surgery
No	-	-	-	-
Yes	0.33 (0.26-0.41)	<0.0001	0.34 (0.27-0.43)	<0.0001
Chemotherapy
No	-	-	-	-
Yes	0.65 (0.57-0.75)	<0.0001	0.64 (0.55-0.75)	<0.0001
Radiation
No	-	-	-	-
Yes	0.68 (0.56-0.82)	<0.0001	0.83 (0.67-1.01)	0.0623

HR, hazard ratio; CI, confidence interval; (-) denotes reference group