At-risk individuals need surveillance for familial pancreatic cancer

By Will Boggs MD

NEW YORK (Reuters Health) - Individuals who have multiple close relatives with pancreatic cancer should undergo surveillance for pancreatic cancer, according to updated recommendations from the International Cancer of the Pancreas Screening (CAPS) Consortium.

"Individuals who have at least one first-degree relative with pancreatic cancer who in turn also has a first-degree relative with pancreatic cancer are judged to be at significant increased risk of developing pancreatic cancer (>5% lifetime)," said Dr. Michael Goggins of Johns Hopkins University, in Baltimore, Maryland.

"The average risk is higher in those with a more extensive family history (such as two or three first-degree relatives with pancreatic cancer)," he told Reuters Health by email.

Dr. Goggins and a multidisciplinary team of experts convened in 2018 to update the CAPS consensus recommendations for the management of individuals with increased risk of pancreatic cancer based on family history or germline mutation status.

A complete discussion of the 55 statements on which the group reached consensus appears online October 31 in Gut.

Besides recommending pancreatic surveillance for individuals with multiple first-degree relatives with pancreatic cancer, the consortium also recommends pancreatic surveillance for carriers of germline deleterious variants in one of eight cancer susceptibility genes and for patients with hereditary pancreatitis.

Pancreatic surveillance should begin at age 50 years for individuals who meet familial risk criteria and for mutation carriers, although some experts recommended later surveillance for those with familial risk and earlier surveillance for those with deleterious mutations.

Based on current evidence, MRI/magnetic retrograde cholangiopancreatography (MRCP) and endoscopic ultrasound (EUS) should be the first-line tests for pancreatic surveillance, but ongoing developments in low-dose CT imaging may necessitate reevaluation of its role in surveillance.

Decisions regarding surgical resection of lesions identified during surveillance depend on the individual's estimated risk of pancreatic cancer, operative risk, comorbidities, life expectancy and compliance with surveillance.

High-risk individuals should undergo pancreatic resection for broadly similar indications to individuals without known familial/genetic risk, based on such established guidelines as worrisome features, the authors say. Patients with solid lesions of indeterminate pathology larger than 5 mm should undergo pancreatic resection if additional evaluation fails to yield a definitive preoperative diagnosis.

In 2019, the U.S. Preventive Services Task Force (USPSTF) recommended against pancreatic screening, but its literature review did not include two studies showing that pancreatic surveillance of high-risk individuals can lead to down-staging of pancreatic cancer.

The current CAPS consensus is also that the average lifetime risk of developing pancreatic cancer (about one in 64 in the U.S.) is too low for population-based screening.

"Pancreatic surveillance of high-risk individuals can identify early-stage pancreatic cancer, providing the best chance at long-term survival," Dr. Goggins concluded.

SOURCE: https://bit.ly/2KjxaJ6

Gut 2019.

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