Is Xeloda (Capecitabine) Used for Cholangiocarcinoma?
Yes, capecitabine is used for cholangiocarcinoma, but its role is primarily limited to the adjuvant setting after surgical resection, where it has demonstrated an overall survival advantage compared to surgery alone. 1
Adjuvant Setting (Post-Surgical Resection)
Capecitabine is strongly recommended as adjuvant therapy for all patients who undergo resection of intrahepatic or perihilar cholangiocarcinoma with R0 or R1 margins. 1
- A 6-month regimen of oral capecitabine should be instituted for patients with good performance status (ECOG 0-1) following resection. 1
- The BILCAP trial established this benefit, showing improved overall survival compared to resection alone. 1
- Treatment can be initiated within 12-16 weeks after surgery, with the flexibility to delay up to 16 weeks in resource-constrained settings to minimize healthcare exposure. 1
- For patients with R1 (margin-positive) resections, capecitabine monotherapy can be followed by chemoradiation 5-6 months later. 1
Advanced/Metastatic Disease Setting
Capecitabine is NOT recommended as standard first-line therapy for advanced cholangiocarcinoma. 1
- Cisplatin-gemcitabine remains the established standard of care for palliative chemotherapy in advanced disease. 1
- There is insufficient evidence to recommend oral chemotherapies like capecitabine in the neoadjuvant setting when surgery and locoregional therapies are unavailable. 1
Alternative Uses in Advanced Disease
Capecitabine may be considered in specific circumstances for advanced cholangiocarcinoma:
- As part of combination regimens: Gemcitabine plus capecitabine combinations have shown activity in phase II trials with response rates of 13-34% and clinical benefit rates up to 85%. 1, 2, 3, 4
- When cisplatin-gemcitabine is contraindicated: CAPOX (capecitabine plus oxaliplatin) is recommended when standard therapy cannot be used. 1
- With concurrent radiation: Capecitabine can be substituted for 5-FU during chemoradiation for patients without metastatic disease. 1
- Second-line therapy: Limited case reports suggest capecitabine may achieve disease stabilization after progression on first-line therapy. 5
Important Clinical Caveats
- Performance status matters: The benefit of any chemotherapy, including capecitabine-containing regimens, is most pronounced in patients with ECOG 0-1. 1
- Hepatic dysfunction: Mild to moderate hepatic impairment from liver metastases does not require dose adjustment of capecitabine, though caution is warranted. 6
- Quality of life focus: In advanced disease, maintaining quality of life should be the primary endpoint, with survival as secondary. 1
- Avoid monotherapy in advanced disease: Single-agent capecitabine is inferior to combination regimens and should not be used as standard first-line therapy for metastatic cholangiocarcinoma. 1
The evidence strongly supports adjuvant capecitabine after resection but does not establish it as standard therapy for advanced disease, where cisplatin-gemcitabine (with or without immunotherapy) remains the preferred approach. 1