Treatment patterns and survival outcomes in elderly patients with intrahepatic cholangiocarcinoma: NCDB analysis

Intrahepatic cholangiocarcinoma (ICC) is a rare malignancy with a poor prognosis and rising incidence that is most commonly diagnosed in older adults. However, elderly patients remain underrepresented in clinical trials, limiting evidence to guide treatment selection in this population. Using the National Cancer Database, we evaluated age-associated differences in treatment patterns and overall survival in patients with nonmetastatic ICC diagnosed between 2004 and 2020, comparing elderly (>65 years) and younger (≤65 years) cohorts. Among 10,342 patients, 5,259 (50.9%) were elderly. Treatment groups included surgery only, chemotherapy only, radiotherapy only, chemotherapy plus radiotherapy, surgery plus chemotherapy or radiotherapy, and trimodality therapy. Among patients with operable disease, elderly patients were less likely to receive trimodality therapy (8.8% vs 14.4%) or surgery plus chemotherapy/radiotherapy (33.2% vs 41.5%) and more likely to undergo surgery alone (58.0% vs 44.1%). Among inoperable patients, elderly patients were less likely to receive chemotherapy-based treatment and more likely to receive radiotherapy alone (7.2% vs 2.8%). In both age groups, treatment strategies incorporating surgery were associated with significantly improved survival compared with nonsurgical approaches. In elderly patients, survival did not significantly differ among the 3 surgical treatment groups at 1, 2, or 5 years. Among nonsurgical elderly patients, chemotherapy plus radiotherapy was associated with improved 1-year (67.6% vs 58.3%) and 2-year overall survival (36.4% vs 26.0%) compared with chemotherapy alone, while radiotherapy alone produced outcomes comparable to chemoradiation. In summary, within the inherent limitations of a retrospective NCDB analysis, we observed that elderly patients with nonmetastatic ICC were more likely to receive treatment de-intensification in both surgical and nonsurgical settings. Furthermore, while surgery remained strongly associated with survival across all patients, in the inoperable setting, we observed that the addition of radiation therapy to the primary site was associated with improved short-term survival outcomes compared to those who only received systemic therapy. These observations should be considered hypothesis-generating and warrant further evaluation using more granular clinical, pathologic, and treatment-specific data.