Two small steps forward emanated from the ASCO Gastrointestinal Cancers Symposium going on this week, and they both raise the difficult issue of very small gains and what they mean. In patients with advanced pancreatic cancer, the addition of the chemotherapy agent Abraxane (albumin-bound paclitaxel) to the standard chemotherapy Gemzar (gemcitabine) improved survival by a median of a little under two months. There are no standard therapies for stomach cancer in the second line, and in another study presented, the use of Taxotere (docetaxel) in this setting improved survival by a median of 1.5 months. What are we to make of these small gains? Are they worthwhile? The answer depends on who you ask, but from my perspective as a medical oncologist, these are truly welcome advances. First of all, we have to recognize that these are average gains, and for a small number of patients the gains could be much longer--maybe exceeding a year. Second, while we recognize that side effects and financial costs have to be reflective of the overall benefit, we also know that these small steps add up, and more importantly lay the foundation for bigger improvements down the line. We never would have enjoyed the success of drugs like Herceptin for breast cancer or stem cell transplant for leukemia if it were not for the chemotherapy underpinnings that themselves may not be as glamorous or ground-breaking, but are very important components of treatment. However, as we help our patients and families through difficult treatment decisions, we have to be very frank about the projected risks and benefits and must have realistic expectations to temper the hope we all naturally experience.