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Early diagnosis of pancreatic cancer

Early diagnosis of pancreatic cancer. Moderators: Banke Agarwal, MD David Linehan, MD Panelists: Suresh Chari, MD Michael Goggins, MD David Whitcombe, MD Maurits Weirsema, MD. Why is early diagnosis desirable.

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Early diagnosis of pancreatic cancer

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  1. Early diagnosis of pancreatic cancer Moderators: Banke Agarwal, MD David Linehan, MD Panelists: Suresh Chari, MD Michael Goggins, MD David Whitcombe, MD Maurits Weirsema, MD

  2. Why is early diagnosis desirable • Despite considerable investment in improving therapy, the outcomes in pancreatic cancer have not changed much in past several decades • Approximately 85% of patients have Stage IV disease at the time of initial presentation Baxter et al, Ann Surg Oncol 2007

  3. Why is early diagnosis desirable? Baxter et al, SEER database

  4. The outcomes in patients with smaller tumors are consistently better than those with larger tumors in several published studies

  5. Survival and resectability in patients with pancreatic cancer based on tumor size N=540 Washington University Pancreas Cancer Database 2000-2007 (unpublished) Agarwal et al Pancreas 2008

  6. Size of pancreatic tumor at diagnosis over past few decades

  7. Why are we not diagnosing early cancers despite improvements in imaging? • Patients with early cancers are usually asymptomatic and do not present for medical attention • Early cancers noted in asymptomatic patients are often overlooked by radiologists

  8. Gangi et al AJR 2004

  9. Why renewed emphasis on early diagnosis now? • Improved resolution with CT/MRI • Advent of EUS-FNA to provide cytologic diagnosis in patients with early stage pancreatic cancers • Advances in molecular testing • Better understanding of pathogenesis and natural history of pancreatic cancer • Less nihilism?

  10. Attempts at early diagnosis of pancreatic cancer ??? pancreatic cancer screening = Can we identify an at-risk population? Is there an identifiable prodrome?

  11. Characteristics of diseases amenable to screening • Substantial morbidity or mortality if untreated • High clinical prevalence • High risk populations • Existence of critical point and appropriate therapy • Low incidence of pseudo-disease

  12. What speaks against screening? • Harm due to screening • Complications • Overtreatment • Low yield/cost • No proof that stage migration results in improved outcome

  13. Q. Is there a good case for screening pancreatic cancer • In general population? • Incidence is 1 in 100,000 • In high risk patient groups?

  14. Prevalence of cancers that are currently screened • Colon cancer - • Breast cancer - • Lung cancer ? - • Cervical cancer - • Prostate cancer -

  15. Characteristics of screening test • Test accuracy • Test reproducibility • Test safety, availability and cost effectiveness

  16. Which tests are best potential candidates for pancreatic cancer screening • Serum markers • Cross sectional imaging with spiral CT or MRI • EUS/FNA • ERCP • Abdominal US • None of the above

  17. Potential strategies for diagnosing pancreatic cancer in early stages • Identification of high risk groups for screening • Screening/surveillance of patients with familial or environmental predisposition • Development of molecular biomarkers for screening or identifying high risk population

  18. Enriched populations for screening for pancreatic cancerSuresh Chari- 10 min • Are there any enriched population subsets with higher prevalence of pancreatic cancer? • New onset diabetes mellitus • Idiopathic acute pancreatitis in the elderly • New diagnosis of chronic pancreatitis • New onset unipolar depression in the elderly • What percentage of pancreatic cancers have associated above presentations? • What percentage of patients with above presentations have pancreatic cancer? • Can we further enrich above populations based on: • Age, h/o smoking • Further defining the clinical syndrome • Use of serum markers

  19. Familial pancreatic cancersDavid Whitcomb 10 mins • What proportion of pancreatic cancers are familial? • What is the risk of pancreatic cancer in various familial conditions? • What are the familial conditions where surveillance for pancreatic cancer would seem justified? • What are the currently available means for evaluating these patients for pancreatic cancer and how effective are they? • Will lessons learned in familial cancers apply to sporadic ones?

  20. Molecular markers to aid in early diagnosis of pancreatic cancerMichael Goggins 10 mins • What will be the required performance characteristics of a serum molecular marker to be • Useful in screening of pancreatic cancer • Diagnosis of pancreatic cancer • Prognostication • Are there any molecular markers in the horizon that can potentially be used for above purposes? • What is the current state of the art in development of biomarkers for pancreatic cancer? • Is there a precursor in pancreatic cancer carcinogenesis (analogous to HGD e.g.,PanIN3) that can be reliably diagnosed pre-operatively.

  21. How can EUS/FNA help in early diagnosis of pancreatic cancerMaurits Wiersema 10 mins • What are the performance characteristics of EUS-FNA for identifying and diagnosing early tumors? • How does EUS/FNA compare with CT or MRI for diagnosis of early cancers? • What is the risk of complications with EUS and EUS-FNA? • Can EUS potentially be used for detecting and diagnosing pancreatic cancer in enriched population subsets? • Role of EUS in diagnosing cancer in patients with subtle/non-specific findings suggestive of cancer on CT scan/MRI? • Are there workforce issues if screening became generally accepted? • Is there a realistic mechanism for quality control?

  22. What are the performance characteristics of EUS-FNA for identifying and diagnosing early tumors? • EUS is more sensitive than MDCT for tumor detection (98% vs 86%) with a more marked difference in smaller tumors – DeWitt 2004 Ann Intern Med • Operating characteristics for EUS in precursor lesions is unknown – Canto 2006 CGH, Kimmey 2002 GIE • PanIN equivalents – are changes of chronic pancreatitis a surrogate? • IPMN • < 1 cm masses

  23. What are the performance characteristics of EUS-FNA for identifying and diagnosing early tumors? • 72% of high risk patients have features of chronic pancreatitis vs 14% of controls • 25% of patients in high risk kindreds will have a ‘neoplastic’ abnormality on initial or short term follow up • The estimated cumulative frequency of pancreatic cancer in this group is 5-40% • EUS is sensitive but specificity is problematic Canto CGH 2004 and 2006, Levy CGH 2006

  24. How does EUS/FNA compare with CT or MRI for diagnosis of early cancers? EUS FNA of Pancreas Masses When CT FNA or ERCP Sampling are Negative Gress et al, Annals of Internal Medicine 2001

  25. How does EUS/FNA compare with CT or MRI for diagnosis of early cancers? • Diagnostic yield in enriched screening cohort • EUS 7 of 8 • CT 5 of 8 • ERCP 2 of 8 • EUS FNA can show mucinous material and dysplasia which may be helpful Canto CGH 2004 and 2006, Levy CGH 2006

  26. What is the risk of complications with EUS and EUS-FNA? • EUS similar to EGD • 1-2% incidence of pancreatitis with FNA

  27. Post EUS FNA Pancreatitis/Duct Leak

  28. Post EUS FNA Pancreatitis/Duct Leak

  29. Post EUS FNA Pancreatitis/Duct Leak

  30. Can EUS potentially be used for detecting and diagnosing pancreatic cancer in enriched population subsets? • Yes • IPMN is a common precursor • Subtle abnormalities may not be uniformly recognized (hypoechoic foci, inhomogeneity) • Specificity issues remain

  31. Role of EUS in diagnosing cancer in patients with subtle/non-specific findings suggestive of cancer on CT scan/MRI? Tumor Detection in Patients with Suspected Pancreas Cancer Fletcher 2003 Radiology

  32. Summary • Are there workforce issues if screening became generally accepted? • No reimbursement • Probably the most difficult EUS exam to perform • Is there a realistic mechanism for quality control? • US interobserver agreement varies depending on severity of abnormality • Readily available gold standard is available

  33. Questions to panel • What is the current status of pancreas cancer screening or early diagnosis today? • Who should be screened? • How much should the population be enriched before testing for pancreatic cancer becomes justifiable? • How often? What age should we start/stop? • What modality?

  34. Questions to panel • What is the future of pancreas cancer screening or early diagnosis? • EUS • Biomarkers • Where should we look (serum, plasma, pancreatic fluid, urine)? • Functional or molecular imaging • Can we “see” PanIns?

  35. Questions to panel • Will stage migration/early detection lead to better outcomes? • What are the impediments to screening and how do we overcome them? • Is there a role for prophylactic pancreatectomy?

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