Surveillance identifies early pancreatic cancer in some high-risk individuals

Last Updated: 2016-04-26

By Will Boggs MD

NEW YORK (Reuters Health) - Long-term surveillance identifies resectable pancreatic cancer in individuals with CDNK2A mutations, researchers report.

"No progress has been made in the treatment of pancreatic cancer since the introduction of Whipple surgery 80 years ago," Dr. Hans Vasen from Leiden University Medical Center, Belgium, told Reuters Health by email. "The outcome of the present study may be considered as a first step in the improvement of the prognosis of patients with this highly aggressive tumor."

Hereditary factors probably play a role in the development of pancreatic ductal adenocarcinoma (PDAC) in 3% to 5% of all patients, Dr. Vasen and colleagues note in the Journal of Clinical Oncology, online April 25. But early detection of PDAC or precursor lesions (PRLs) in these individuals could allow curative surgical treatment, they add.

The researchers assessed whether surveillance with MRI, MR cholangiopancreatography (MRCP), and endoscopic ultrasound (EUS) leads to the detection of early-stage PDAC or relevant PRLs and thereby improves prognosis in a study of 178 CDKN2A mutation carriers, 19 BRCA1/BRCA2 or PALB2 mutations, and 214 individuals at risk for familial pancreatic cancer (FPC).

Surveillance detected PDAC in 13 and cystic lesions in 26 of the 178 CDKN2A mutation carriers, the team found.

Of the nine patients who underwent surgery for PDAC, five had tumor-free lymph nodes and seven had tumor-free resection margins. The four PDAC patients who did not undergo surgery had metastatic or extensive local disease (n=3) or metastatic disease from another cancer (n=1).

The overall five-year survival rate of the PDAC patients was 24%, considerably higher than the 4% to 7% reported for symptomatic sporadic PDAC.

The researchers screened 14 patients to detect one PDAC, and 67 MRIs were needed to detect one PDAC.

Only one individual in the BRCA1/BRCA2/PALB2 mutation group developed PDAC, and two additional patients in this group underwent surgery for cystic lesions (both with pancreatic intraepithelial neoplasms and other low-grade lesions).

Surveillance identified lesions suspicious for PDAC in three women and cystic lesions in 112 other individuals in the FPC group. Thirteen of these latter individuals underwent surgery for what turned out to be high-risk PRLs in four cases, and four of these 13 developed postoperative complications.

"Surveillance of CDNK2A mutation carriers is relatively successful, detecting most PDACs at a resectable stage," the researchers conclude. "The benefit of surveillance in families with FPC is less evident."

Dr. Vasen feels that screening for pancreatic cancer should be offered to people with a genetic predisposition for the disease. "Such patients should be referred to expert centers with ongoing screening programs and a high volume of pancreatic surgery," he said. "Before starting the program, it is important to discuss all advantages and disadvantages of the program."

Dr. Teresa A. Brentnall from University of Washington Medical Center in Seattle, who wrote an editorial related to this report, told Reuters Health by email, "Although one would think that (the new) findings would be self-evident, the value of early detection in pancreatic cancer has been challenged by some clinicians and scientists as futile."

"This study shows very clearly the clinical value of early detection and underscores the need for biomarkers and better methods for imaging for incipient cancer," she said.

"I think the success of the surveillance programs is based on the multi-specialty experience of the team of doctors who care for these high-risk patients," Dr. Brentnall said. "The teams include gastroenterologists, radiologists, and surgeons all of whom have a deep knowledge base regarding benign and malignant diseases of the pancreas. For these patients, knowing when not to operate is just as important as knowing when to operate."

SOURCE: http://bit.ly/1MVfAss and http://bit.ly/1WnrFZi

J Clin Oncol 2016.