What are the AGA guidelines for pancreatic cancer screening?

Updated: Oct 02, 2020
  • Author: Tomislav Dragovich, MD, PhD; Chief Editor: N Joseph Espat, MD, MS, FACS  more...
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Answer

In 2020, the AGA published a clinical practice guideline update containing best practice advice for identifying and screening patients at high risk for pancreatic cancer. The goal of screening is to detect resectable stage 1 pancreatic ductal adenocarcinoma, and high-risk precursor neoplasms such as intraductal papillary mucinous neoplasms (IPMNs) with high-grade dysplasia and some enlarged pancreatic intraepithelial neoplasias. [94]

The guideline recommends against screening average-risk individuals for pancreas cancer. The guideline recommends considering screening 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, and in patients with genetic syndromes associated with an increased risk of pancreas cancer, including all patients with the following [94] :

  • Peutz-Jeghers syndrome
  • Hereditary pancreatitis
  • CDKN2A gene mutation
  • One or more first-degree relatives with pancreas cancer with Lynch syndrome
  • Mutations in BRCA1, BRCA2, PALB2, and ATM genes

Further recommendations are as follows [94] :

  • Consider genetic testing and counseling 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.
  • When possible, high-risk patients undergoing pancreas cancer screening should participate in a registry or be referred to a pancreas center of excellence.
  • Begin pancreas cancer screening in high-risk individuals at age 50, or 10 years younger than the initial age of familial onset. Initiate screening at age 40 in CKDN2A and PRSS1 mutation carriers with hereditary pancreatitis and at age 35 in patients with Peutz-Jeghers syndrome.
  • MRI and EUS in combination are the preferred screening modalities for pancreas cancer screening.
  • 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 6-12 months directed towards lesions determined to be low risk (by a multidisciplinary team). EUS evaluation within 3-6 months for indeterminate lesions and within 3 months for high-risk lesions, if surgical resection is not planned. New-onset diabetes in a high-risk patient should lead to additional diagnostic studies or change in surveillance interval.
  • Decisions regarding therapy directed towards abnormal findings detected during screening should be made by a dedicated multi-disciplinary team together with the high risk individual and their family.
  • Surgical resection should be performed at high volume centers.
  • Consider discontinuing pancreas cancer screening in high-risk individuals when they are more likely to die of causes unrelated to pancreas cancer, due to co-morbidity and/or are not candidates for pancreas resection.
  • The limitations and potential risks of pancreas cancer screening should be discussed with patients prior to initiating a screening program.

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