Still No Call for Widespread Screening for Pancreatic Cancer, but USPSTF Says Yes for Those With Known Risk

The US Preventive Services Task Force (USPSTF) continues its recommendation against screening everyone for pancreatic cancer, but for the first time this week noted this does not apply to people with known genetic syndromes of family history of the deadly cancer.

It’s an important shift for the diagnosis of a cancer that, while still relatively rare, is becoming a leading cause of cancer death in the United States as survival rates improve for other types.

USPSTF’s recommendation of “D” for population-wide screening for pancreatic cancer, published in JAMA Internal Medicine,¹ means the evidence shows that screening in asymptomatic adults demonstrates moderate or high certainty of no net benefit or that harms will outweigh benefits. An accompanying editorial in JAMA Surgery states that this conclusion is not a surprise, given the potential for false-positive results and harms of treatment.²

This is the first update of USPSTF recommendations on pancreatic cancer screenings in 15 years. It’s now the fourth-leading cause of cancer death, although it is the ninth most common cancer among women and the 10th most common among men.

Pancreatic cancer remains one of the most frustrating diseases for oncologists. Because patients often have no symptoms early on, it’s frequently caught in later stages, when surgery may no longer be an option. Thus, the 5-year survival rate for pancreatic cancer remains a dismal 9% overall, according to the American Cancer Society, although the rate is 34% for localized cancer.

With those statistics, why not screen everyone? As Ralph H. Hruban, MD, and Keith D. Lillemoe, MD, note in their editorial, even the most sensitive test (99% specificity) will generate a number of false positives when applied to the general population, leading to more testing and perhaps surgery.

Still, Hruban and Lillemoe found hope in the task force’s acknowledgment that evidence for the usefulness of genetic biomarkers in pancreatic cancer is rapidly improving. “Populations with significantly increased risk can now be targeted for screening, greatly increasing their positive pretest probability,” they write.

Shift for Those at High Risk

The Pancreatic Cancer Action Network (PanCAN) took note of critical language changes for people with high risk. “USPSTF has made an important change to its definition of the ‘general population.’ For the first time, the USPSTF has noted their recommendation does not apply to people with a known inherited genetic syndrome or strong family history of pancreatic cancer.

“Instead, they are encouraged to participate in surveillance programs at ‘experienced centers, ideally under research conditions,’” according to an article on the advocacy group’s website.

PanCAN took note of this spring’s update to guidelines from the National Comprehensive Cancer Network, which called for all pancreatic cancer patients to receive germline cancer screening.

“It’s thought that about 10% of pancreatic cancer cases are hereditary—meaning the person was born with an alteration in their DNA that increase the risk of developing the disease,” Lynn Matrisian, PhD, MBA, PanCAN chief science officer, said in the group’s statement. She said a recent finding showed that a similar percentage of people have germline mutations whether or not they have a known family history of pancreatic or other cancers.

More Research Needed

In its recommendation, the USPSTF called for more research to develop better screening tests with higher sensitivity and higher specificity for pancreatic cancer, with greater ability to detect high-grade lesions that serve as early warnings of pancreatic cancer. More work is needed, the task force said, to understand the relationship between these “precursor lesions” and how cancer develops, and in which patients.

Given the increase in evidence of links between obesity, diabetes, and pancreatic cancer, the USPSTF said, “studies of screening in persons who may be at increased risk (eg, adults with new-onset diabetes) may be warranted. Research on improved stratification may also help advance the field of pancreatic cancer screening.”

References

1. US Preventive Services Task Force. Screening for pancreatic cancer: US Preventive Services Task Force reaffirmation recommendation statement. JAMA. 2019;322(5):438-444. doi:10.1001/jama.2019.10232.
2. Hruban RH, Lillemoe KD. Screening for pancreatic cancer gets a D, but the student is improving [published online August 6, 2019]. JAMA Surg. doi:10.1001/jamasurg.2019.2832.