AGA guidance: When to screen for pancreas cancer

AGA has released a new Clinical Practice Update providing best practice advice for clinicians screening and diagnosing pancreatic cancer in high-risk individuals.

In the AGA Clinical Practice Update on Pancreas Cancer Screening in High-Risk Individuals: Expert Review, published in Gastroenterology’s July issue, the authors provide the following best practice advice statements to address key issues in clinical management of these patients:

CLINICAL PRACTICE ADVICE

1. Pancreas cancer screening should be considered in patients determined to be at high risk, including first-degree relatives of patients with pancreas cancer with at least two affected genetically related relatives.
2. Pancreas cancer screening should be considered in patients with genetic syndromes associated with an increased risk of pancreas cancer, including all patients with Peutz–Jeghers syndrome, hereditary pancreatitis, patients with CDKN2A gene mutation, and patients with one or more first-degree relatives with pancreas cancer with Lynch syndrome, and mutations in BRCA1, BRCA2, PALB2, and ATM genes.
3. Genetic testing and counseling should be considered for familial pancreas cancer relatives who are eligible for surveillance. A positive germline mutation is associated with an increased risk of neoplastic progression and may also lead to screening for other relevant associated cancers.
4. Participation in a registry or referral to a pancreas Center of Excellence should be pursued when possible for high-risk patients undergoing pancreas cancer screening.
5. Clinicians should not screen average-risk individuals for pancreas cancer.
6. Pancreas cancer screening in high-risk individuals should begin at age 50 years, or 10 years younger than the initial age of familial onset. Screening should be initiated at age 40 years in CKDN2A and PRSS1 mutation carriers with hereditary pancreatitis and at age 35 years in the setting of Peutz–Jeghers syndrome.
7. Magnetic resonance imaging and endoscopic ultrasonography (EUS) should be used in combination as the preferred screening modalities in individuals undergoing pancreas cancer screening.
8. The target detectable pancreatic neoplasms are resectable stage I pancreatic ductal adenocarcinoma and high-risk precursor neoplasms, such as intraductal papillary mucinous neoplasms with high-grade dysplasia and some enlarged pancreatic intraepithelial neoplasias.
9. Screening intervals of 12 months should be considered when there are no concerning pancreas lesions, with shortened intervals and/or the performance of EUS in six to 12 months directed towards lesions determined to be low risk (by a multidisciplinary team). EUS evaluation should be performed within three to six months for indeterminate lesions and within three months for high-risk lesions, if surgical resection is not planned. New-onset diabetes in a high-risk individual should lead to additional diagnostic studies or change in surveillance interval.
10. Decisions regarding therapy directed towards abnormal findings detected during screening should be made by a dedicated multidisciplinary team together with the high-risk individual and their family.
11. Surgical resection should be performed at high-volume centers.
12. Clinicians should consider discontinuing pancreas cancer screening in high-risk individuals when they are more likely to die of non-pancreas cancer–related causes due to comorbidity and/or are not candidates for pancreas resection.
13. The limitations and potential risks of pancreas cancer screening should be discussed with patients before initiating a screening program.

For more information, view the full AGA Clinical Practice Update on Pancreas Cancer Screening in High-Risk Individuals: Expert Review