Should I order an MRI for an elderly patient with a family history of pancreatitis cancer and a normal HbA1c level?

Should You Order an MRI for This Elderly Patient?

No, you should not order an MRI for pancreatic cancer screening based solely on having one sibling with pancreatic cancer and a normal HbA1c. This patient does not meet established criteria for formal pancreatic cancer screening programs. 1, 2, 3

Why This Patient Does Not Qualify for Screening

Having only one first-degree relative (brother) with pancreatic cancer does not meet the threshold for high-risk screening. The established guidelines are clear about who qualifies:

Minimum Family History Requirements for Screening:

• At least TWO first-degree relatives with pancreatic cancer, OR 4, 1, 2
• Three or more blood relatives with pancreatic cancer (with at least one being first-degree), OR 1, 2
• Two affected blood relatives with at least one first-degree relative 1, 2

Exception - When Single First-Degree Relative IS Sufficient:

• Only if the patient carries a known pathogenic germline mutation (BRCA1, BRCA2, PALB2, ATM, or Lynch syndrome genes) PLUS has one affected first-degree relative 4, 1, 2
• Carriers of CDKN2A or STK11 mutations require screening regardless of family history 4

The HbA1c Finding

The HbA1c of 5.4% is normal and reassuring. While elevated HbA1c has been associated with increased pancreatic cancer risk in high-risk individuals (every 1% increase associated with 36% increased odds), this patient's value is well within normal range. 5 New-onset diabetes in a high-risk individual would warrant immediate screening, but this does not apply here. 1

Appropriate Next Steps

What You Should Do Instead:

1. Reassure the patient that having one sibling with pancreatic cancer does not significantly elevate their risk to warrant formal screening 3

2. Consider genetic counseling and testing if: 3

   • The brother's pancreatic cancer occurred at a young age (<50 years)
   • There are additional concerning features in the family history
   • Other cancers cluster in the family suggesting hereditary cancer syndrome

3. Address modifiable risk factors: 3

   • Smoking cessation (if applicable) - smoking significantly increases pancreatic cancer risk
   • Maintain healthy weight
   • Standard age-appropriate cancer screening for other malignancies

4. Reassess if circumstances change: 3

   • If additional family members develop pancreatic cancer
   • If genetic testing reveals a high-risk mutation

When Would Screening Be Appropriate?

If genetic testing reveals a pathogenic mutation (BRCA2, PALB2, ATM, Lynch syndrome) in this patient, THEN screening would be recommended starting at age 45-50 or 10 years younger than the brother's age at diagnosis, whichever is earlier. 4, 1

The screening modality would be alternating MRI/MRCP and endoscopic ultrasound (EUS) at 12-month intervals, performed at a high-volume center with expertise. 4, 1, 2

Common Pitfall to Avoid

Do not conflate general population screening with high-risk screening. The lifetime risk of pancreatic cancer in the general population is only 1.3%, and screening is not recommended unless the risk exceeds 5% (fivefold increase). 3 Having one affected first-degree relative does not reach this threshold. 3