SCREENING HIGH RISK PATIENTS FOR PANCREATIC CANCER MAY BE EFFECTIVE

NEW YORK (Reuters Health) Oct 06 - Patients at high risk for pancreatic cancer can be effectively screened, allowing neoplasms to be identified early, researchers report in Clinical Cancer Research for October 15.

"Our comprehensive strategy of imaging and genetic evaluation of high-risk individuals can identify pre-neoplastic pancreas lesions, as well as pancreas and extra-pancreatic cancers that can be resected with curative intent," Dr. Harold Frucht told Reuters Health in emailed comments.

Dr. Frucht, of Columbia University College of Physicians & Surgeons, New York-Presbyterian Hospital, and colleagues note that pancreatic cancer is the fourth leading cause of cancer deaths in most western countries. "Due to the rapid progression and almost uniform fatality of the disease, early detection through screening will be essential to improve outcomes," they point out.

While no screening strategy is feasible for the general population, screening is thought worthwhile in individuals with a hereditary predisposition to develop pancreatic cancer. About 3% to 16% of pancreatic cancer is thought to be either syndromic or familial.

"It is not yet entirely clear what percentage of pancreatic cancer patients are at high-risk, and which individuals would benefit from screening for pancreatic cancer," Dr. Frucht said. "As pancreatic cancer screening requires costly imaging and physician expertise, only the highest risk individuals should be considered for screening. At most, the high-risk pancreas cancer patients would likely be less than 15% of all pancreas cancers, specifically those with family histories consistent with a heritable syndrome."

The researchers report their initial experience with a high-risk pancreatic cancer screening program in a small study of 51 subjects from 43 families, who were tested for mutations linked to hereditary cancer syndromes and followed prospectively with endoscopic ultrasound or MRI.

"Endoscopic ultrasound revealed two patients with pancreatic cancer (one resectable, one metastatic), five with intraductal papillary mucinous neoplasms (IPMN), seven with cysts, and six with parenchymal changes," the team reports.

Furthermore, four neoplasms at other sites were identified. "We are somewhat gratified at the number of significant non-pancreatic lesions that were detected, as this demonstrates that genetic evaluation is integral to the screening process," said Dr. Frucht. He added that heritable diseases are "systemic" and should be comprehensively approached.

Nine patients underwent surgery with curative intent, except for the one case of metastatic pancreatic cancer. "All patients remain alive and without complications of screening," the team reports.

"One of the limiting factors of this study, as well as all other studies on pancreas cancer screening, is that it is impossible to know how many patients that did not go to surgery have significant pre-neoplastic lesions that are not able to be detected on imaging. We also do not know the natural history of many of these lesions, which makes it difficult to know what would have developed in the individuals that did go to surgery," Dr. Frucht cautioned.

Still, he concluded, "Ongoing research will better define genetic and environmental risk factors for pancreas cancer, and will enable improved risk stratification and identification of at-risk individuals. It will also allow us to determine which testing modalities are most useful, and at what frequency."

Clin Cancer Res. Posted October 15, 2010. Abstract