Pancreatic Cancer Screening in Asymptomatic Adults Still Not Recommended

The United States Preventive Services Task Force (USPSTF) reaffirmed its recommendation against screening for pancreatic cancer in asymptomatic adults, concluding that the potential benefits of screening do not outweigh potential harms, according to a statement published in JAMA.

This recommendation does not apply to people at high risk for the disease, according to an audio interview between JAMA and USPSTF panel member Chyke A. Doubeni, MD, MPH, of the Mayo Clinic, Rochester, Minn. This includes people with certain inherited genetic syndromes or a family history of pancreatic cancer.

“If we had an effective screening test that can detect [pancreatic cancer] early and had treatments that are effective to treat early conditions and prevent death, than you have a good scenario in which screening can be helpful in this very devastating condition,” Doubeni said in the JAMA audio interview. “Even for early conditions, the survival rate is not as good as we would like it to be. We have a ways to go to get treatments that are really effective and have fewer harms than is the case with current treatment modalities that we have, which is basically major surgery.”

The reaffirmation was issued as an update to the 2004 USPSTF recommendation on screening for pancreatic cancer. The decision was based on a review of evidence weighing the benefits and harms of screening, the diagnostic accuracy of screening tests, and the benefits and harms of treatment of screen-detected or asymptomatic pancreatic cancer.

New evidence included 13 cohort studies, mostly conducted in high-risk populations. The USPSTF found no new substantial evidence that would changes its prior recommendation.

In an editorial published in JAMA Surgery, Ralph H. Hruban, MD, of John Hopkins University School of Medicine, and Keith D. Lillemoe, MD, of Massachusetts General Hospital, wrote that no one dedicated to early detection of pancreatic cancer could be surprised by this USPSTF recommendation, adding that no real progress will be made until clinicians in all specialties “set aside the generally nihilistic attitude toward the disease and pursue aggressive diagnostic and therapeutic actions”.

“One can easily imagine the day in which high-risk individuals will be screened using new molecular-based technologies. In parallel, all abdominal imaging will be scanned using deep learning and other approaches to identify subtle changes in the pancreas,” they wrote. “Individuals found to have a precancer will not undergo invasive surgery, but instead will receive a therapeutic vaccine that will selectively kill the precancerous lesion before it has the opportunity to progress to invasive carcinoma.”

In another editorial published in JAMA Internal Medicine, Anne Marie Lennon, MD, PhD, of Sidney Kimmel Comprehensive Cancer Center, John Hopkins Medicine, and colleagues discussed many of the challenges associated with screening for pancreatic cancer including the location of the pancreas, a tendency for rapid progression, and a low prevalence in asymptomatic adults. In addition, current imaging technology does not allow for accurate distinction between high-grade dysplasia and low-grade precursors.

Among the methods Lennon and colleagues discussed to address these challenges is the identification of high-risk populations in whom screening would be of the greatest benefit.

“High-risk populations include individuals with intraductal papillary mucinous neoplasms or mucinous cystic neoplasms; a strong family history of pancreatic cancer (at least 2 family members); a germline pathogenic variant in BRCA1, BRCA2, p16/ CDKN2A, PALB2, STK11, ATM, PRSS1, and the DNA mismatch repair genes; and older individuals with new onset diabetes mellitus,” they wrote. “Surveillance is currently recommended for individuals who are found to have an IPMN or MCN, and the International Cancer of the Pancreas Screening Consortium has developed guidelines for screening high-risk individuals.”