USPSTF Draft Recommendation

Don't Screen Asymptomatic Adults for Pancreatic Cancer

February 19, 2019 12:11 pm Chris Crawford

Although uncommon overall, pancreatic cancer is a deadly disease -- ranking as the third most common cause of cancer death in the United States.

[illustration of pancreatic cancer]

Sadly, most cases of pancreatic cancer aren't found early enough to be treated effectively, and outcomes are poor. Even when found early and treated with surgery, the average survival after pancreatic cancer is only 36 months.

To compound this, there's a lack of evidence to suggest that screening tests for pancreatic cancer improve patient outcomes.

Furthermore, some tests for pancreatic cancer are invasive and can lead to pain, adverse reactions to anesthesia, false-positive results and, sometimes, pancreatitis.

Even if pancreatic cancer is found, followup treatment such as pancreatectomy, or surgery to remove all or a portion of the pancreas, can have significant harms, including bleeding, weeks of recovery time and a small risk of death.

Story Highlights
  • On Feb. 5, the U.S. Preventive Services Task Force (USPSTF) posted a draft recommendation statement and draft evidence review on screening for pancreatic cancer.
  • Based on current evidence, the USPSTF recommended against screening for pancreatic cancer in asymptomatic adults -- a "D" recommendation.
  • This draft recommendation statement reaffirms the task force's 2004 final recommendation against screening asymptomatic adults for pancreatic cancer, which the AAFP supported at the time.

All of this is according to the U.S. Preventive Services Task Force (USPSTF), which on Feb. 5 posted a draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on screening for pancreatic cancer.

Based on current evidence, the USPSTF recommended against screening for pancreatic cancer in asymptomatic adults -- a "D" recommendation.(www.uspreventiveservicestaskforce.org)

"Although pancreatic cancer is rare, it is a devastating disease with low survival rates," said USPSTF member Chyke Doubeni, M.D., M.P.H., in a news release.(www.uspreventiveservicestaskforce.org) "Unfortunately, we do not currently have an effective test to screen for pancreatic cancer."

This draft recommendation statement is a reaffirmation of the task force's 2004 final recommendation statement(www.uspreventiveservicestaskforce.org) against screening for pancreatic cancer in asymptomatic adults, which the AAFP supported at the time.

In 2004, the USPSTF reviewed the evidence on screening for pancreatic cancer and concluded that the harms of screening for the disease exceeded any potential benefits.

It should be noted that this recommendation does not apply to diagnostic evaluations in patients suspected of possibly having pancreatic cancer.

No other organizations recommend screening for pancreatic cancer in asymptomatic adults, the task force said.

Draft Recommendation Details

To update its 2004 recommendation, the USPSTF commissioned a systematic review on the benefits and harms of screening for pancreatic cancer, the diagnostic accuracy of screening tests for pancreatic cancer, and the benefits and harms of treatment of screen-detected or asymptomatic pancreatic cancer.

The USPSTF said it found no studies that reported on the sensitivity or specificity of CT, MRI or endoscopic ultrasound (EUS) as screening tests for pancreatic cancer.

The task force did, however, find 13 cohort studies on screening for pancreatic cancer using CT, MRI or EUS -- mostly in patients at high familial risk -- that reported on the yield of screening.

Among high-risk participants in all studies, a total of 18 cases of pancreatic cancer were found during all rounds of screening, for a yield of 15.6 cases per 1,000 people.

"The applicability of these data to persons not at high risk of pancreatic cancer is uncertain, and the yield of screening in a population with a lower incidence of pancreatic cancer is likely to be much lower," the task force said.

The USPSTF also noted that "any screening test used in a population with a lower incidence of pancreatic cancer would potentially have a lower positive predictive value and a higher rate of false-positives."

Finally, the task force found no studies on the benefits of screening for pancreatic cancer or on the benefits of treating screen-detected or asymptomatic pancreatic cancer in the general population.

"New, effective screening tests are needed that can find pancreatic cancer earlier," said USPSTF member Chien-Wen Tseng, M.D., M.P.H., M.S.E.E., in the release. "We also need better treatments that can lead to improved survival or a cure with fewer harms."

Family Physician's Perspective

AAFP Commission on Health of the Public and Science member Kenneth Fink, M.D., M.G.A., M.P.H., of Honolulu, told AAFP News the net balance of potential harm exceeded the potential benefit of screening asymptomatic patients for pancreatic cancer, which led to the USPSTF's recommendation against routinely screening this population.

"More importantly, the task force concluded the benefit of treatment in screen-detected patients was small, based on the low prevalence and poor prognosis even when treatment is started at an early stage, and concluded the potential harms for the screened population as moderate," Fink said.

A screening test for pancreatic cancer that would be beneficial, according to Fink, would detect an asymptomatic condition with few false-positive and false-negative results.

"Recommended use of a screening test would depend on the prevalence of the condition, accuracy of the screening test, effectiveness of treatment for the condition, benefit of treating the condition in an asymptomatic state and potential harms," he added.

Fink noted that pancreatic tumors are often asymptomatic in early stages, but may progress from that point at varying rates.

"Once a patient is symptomatic, the symptoms depend on the type of pancreatic cancer," he said. "The classic presentation is painless jaundice, but other symptoms can include weight loss, nausea/vomiting, and abdominal or back pain for exocrine pancreatic cancers. Neuroendocrine tumors can cause symptoms associated with oversecretion of the particular hormone."

To reduce patients' risk for pancreatic cancer, Fink said family physicians can suggest eliminating or at least reducing modifiable risk factors, particularly tobacco use and obesity, as well as other potential risk factors, including diets containing processed meat, elevated sugar intake and high alcohol consumption.

Up Next

The USPSTF is accepting comments on its draft recommendation statement(www.uspreventiveservicestaskforce.org) and draft evidence review(www.uspreventiveservicestaskforce.org) on screening for pancreatic cancer until 8 p.m. ET on March 4. All comments received will be considered as the task force prepares its final recommendation.

The AAFP will review the USPSTF's draft recommendation statement and supporting evidence and will provide comments to the task force. The Academy will release its own recommendation on the topic after the task force finalizes its guidance.

More From AAFP
American Family Physician: Diagnosis and Management of Pancreatic Cancer
(4/15/2014)