Mary F. Mulcahy, MD

Localized pancreatic cancer, whether resectable or unresectable, is a separate entity from metastatic pancreatic cancer. Multiple studies have demonstrated that even in the setting of unresectable disease, the progression-free and overall survival of patients with localized pancreatic cancer exceeds that associated with metastatic pancreatic cancer.

Nearly 150,000 people will be diagnosed with colorectal cancer in the United States in 2006. The impact of this diagnosis will be felt by countless family members, coworkers, and friends. Although screening tests for colorectal cancer have been available and encouraged by medical associations such as the American Cancer Society (ACS) and others, public awareness and compliance has been dismal.

Advanced cancer in the setting of liver dysfunction poses a dilemmafor physicians, as many cancer chemotherapeutic agents undergo hepaticmetabolism. Most cytotoxic drugs have a narrow therapeutic index,and the administration of chemotherapy to patients with liver impairmentresults in complicated safety issues. We present a concise reviewof cancer chemotherapy dosing in the setting of liver dysfunction.Although caution in treating all patients with hepatic failure is essential,the use of certain agents provokes greater concern than others.Continuous-infusion fluorouracil, capecitabine (Xeloda), mechlorethamine(Mustargen), cyclophosphamide, topotecan (Hycamtin), andoxaliplatin (Eloxatin) appear to be relatively well tolerated. On thecontrary, taxanes, vinca alkaloids, irinotecan (Camptosar), andanthracyclines may cause unacceptable toxicity if administered to patientswith poor hepatic function. For many anticancer agents, the paucityof data prohibits formal dosing recommendations, and most guidelinesremain empiric.

Cancers of the gallbladder andbile ducts are uncommon, aggressivemalignancies thatpresent both a diagnostic and therapeuticchallenge. With an annual incidenceof 7,200 cases in the UnitedStates, and the difficulty in diagnosingbiliary tract tumors, there is a paucityof data supporting therapeuticoptions. This comprehensive updateby Daines et al demonstrates the advancesin diagnostic and staging techniques,which have led to appropriatesurgical resection. Despite these advances,the prognosis of gallbladderand cholangiocarcinoma remains bleak,without significant improvement in survival,contrary to the author's optimisticintroduction. There is a lack of activechemotherapy and clinical trials exploringadjuvant and palliative therapy.Guidelines such as those advocated bythe National Comprehensive CancerNetwork (NCCN) help to establish standardsfor the evaluation and treatmentof these uncommon tumors and providea framework for the developmentof clinical trials.[1]