What are the recommendations for pancreatic cancer screening?

Pancreatic Cancer Screening Recommendations

Pancreatic cancer screening is not recommended for the general population but should be offered only to high-risk individuals with specific genetic mutations or strong family history of pancreatic cancer. 1

Who Should Be Screened

Individuals with Genetic Syndromes

• All patients with Peutz-Jeghers syndrome (carriers of LKB1/STK11 gene mutation) should undergo screening regardless of family history 1
• All carriers of CDKN2A (p16) mutations should undergo screening 1
• Carriers of BRCA2, BRCA1, PALB2, ATM mutations with at least one affected first-degree relative (FDR) should be screened 1
• Mismatch repair gene mutation carriers (MLH1, MSH2, MSH6 - Lynch syndrome) with at least one affected FDR should be screened 1

Individuals with Family History of Pancreatic Cancer

• Individuals with three or more affected blood relatives with pancreatic cancer, with at least one being an FDR 1
• Individuals with at least two affected FDRs with pancreatic cancer 1
• Individuals with two affected blood relatives with pancreatic cancer, with at least one being an FDR 1

When to Begin Screening

Age to Start Screening

• For individuals with familial pancreatic cancer (without known genetic mutation): Age 50 or 55 or 10 years younger than the youngest affected blood relative 1
• For specific gene mutation carriers:
  • CDKN2A and Peutz-Jeghers syndrome: Begin at age 40 1, 2
  • BRCA2, BRCA1, PALB2, ATM, and Lynch syndrome: Begin at age 45-50 or 10 years younger than the youngest affected relative 1, 2
  • STK11 (Peutz-Jeghers syndrome): Begin at age 30-35 2
• New-onset diabetes in a high-risk individual should prompt immediate screening regardless of age 1

How to Screen

Recommended Screening Tests

• Initial screening should include:

  • MRI/MRCP (Magnetic Resonance Imaging/Magnetic Resonance Cholangiopancreatography) 1
  • EUS (Endoscopic Ultrasound) 1
  • Fasting blood glucose and/or HbA1c testing 1

• Follow-up screening should alternate between:

  • MRI/MRCP 1
  • EUS 1

• Additional tests when indicated:

  • CA19-9 should be used as an additional test for individuals with worrisome features on imaging 1
  • CT should be performed only when a solid lesion is detected 1
  • EUS-FNA (fine-needle aspiration) should be performed for:
    • Solid lesions ≥5mm 1
    • Cystic lesions with worrisome features 1
    • Asymptomatic main pancreatic duct strictures 1

Screening Intervals

• For individuals with no abnormalities or only non-concerning abnormalities (e.g., pancreatic cysts without worrisome features): 12-month intervals 1
• For individuals with concerning abnormalities that don't immediately warrant surgery: 3-6 month intervals 1
• For CDKN2A (p16) mutation carriers with newly detected concerning pancreatic abnormalities: Repeat imaging within 3-6 months 1

Management of Detected Abnormalities

• Surgery is recommended when:
  • Positive FNA results are obtained 1
  • High suspicion of malignancy exists on imaging 1
  • When surgery is indicated, it should be performed at a high-volume specialty center 1

Goals of Screening

• The primary goal is to detect and treat:
  • Stage I pancreatic cancer confined to the pancreas with negative resection margins 1
  • Pancreatic cancer precursor lesions with high-grade dysplasia (PanIN or IPMN) 1

Common Pitfalls and Caveats

• Screening the general population is not cost-effective or advisable due to the low prevalence of pancreatic cancer relative to the accuracy of detection methods 3
• The diagnostic yield of extensive screening programs can be low, especially considering the uncertain tumorigenic value of low-grade PanIN lesions 4
• Psychological stress for tested individuals and high costs must be considered when recommending screening 4
• Screening and subsequent management should take place at high-volume centers with multidisciplinary teams, preferably within research protocols 1
• Small cystic lesions are commonly detected in high-risk individuals (up to 50%), but most have low malignant potential 1