Pancreatic Cancer Screening in High-Risk Individuals
August 19, 2019
Although the “do not screen” recommendation for pancreatic cancer in the general population continues to hold, experts point to recent data that support surveillance for high-risk individuals.
The “do not screen” recommendation comes from the US Preventive Services Taks Force (USPSTF), which announced recently that the recommendation — issued in 2004 — still stands. The decision, published online August 6 in the Journal of the American Medical Association, was not unexpected because there have been no prospective studies supporting screening for pancreatic cancer in asymptomatic persons since that time.
However, in three accompanying editorials, clinicians and researchers argue the case for screening in high-risk individuals.
All the editorialists make a plea that the USPSTF “do not screen” recommendation should not obscure the great strides that have been made since 2004 in identifying these at-risk individuals who could benefit from surveillance.
People at high risk for pancreatic ductal adenocarcinoma are “outside the purview of the USPSTF,” according to the statement’s evidence report.
All the data that support pancreatic screening are in regard to high-risk individuals. The USPSTF assessed the 13 prospective studies that were available at the time of their first data-review cutoff of April 27, 2018.
Although the USPSTF maintained its “do not screen” recommendation for asymptomatic adults because of the lack of evidence, it indicated that “this recommendation does not apply to these high-risk populations.”
The USPSTF did not make any recommendations for screening these individuals, but the authors of the three editorials stepped up to fill the gap.
Third Leading Cause of Cancer Death
Pancreatic cancer is currently the third leading cause of cancer death in the United States. It is predicted to move to second place by 2030. Approximately 90% of people with the disease die within 5 years of diagnosis. USPSTF coauthor Chyke Doubeni, MD, MPH, in an interview on the JAMA website, stated, “It really is a lethal disease and one we’re concerned about.”
Although there is some evidence that early treatment leads to better outcomes, the window of opportunity is small. Because of the location of the pancreas, pancreatic cancer usually presents at an advanced stage. It also progresses rapidly: patients with stage IV pancreatic cancer were only 1.3 years older on average than patients with stage I disease, according to a recent analysis of the National Cancer Institute’s Surveillance, Epidemiology and End Results database.
At diagnosis, more than half the patients present with metastatic disease. The only treatment that offers a potential cure is pancreatoduodenectomy, which carries perioperative mortality risks of 1% to 8%, according to the USPSTF evidence review.
In an accompanying JAMA editorial, Aimee Lucas, MD, of Icahn School of Medicine at Mount Sinai, and Fay Kastrinos, MD, MPH, of Columbia University, both in New York City, acknowledge that “it could be anticipated that screening for pancreatic cancer in asymptomatic, average-risk individuals would generate more harm than good.” They cite the low prevalence, the potential harms of false positive screening results, and the risks associated with surgery.