Optimizing the Management of Helicobacter PyloriInfectionsApril 8, 2022
- Pancreatic Ductal Adenocarcinoma (PDAC) continues to have a dismal prognosis at the time of presentation.
- Survival is improved with diagnosis at an early stage, but the relatively low incidence of disease, less than optimal screening modalities, and risk of harm with intervention have prompted the U.S. Preventive Services Task Force to recommend against screening for PDAC in average-risk adults.
- This guideline from the American Society for Gastrointestinal Endoscopy (ASGE) utilized both the Grading of Recommendations Assessment, Development and Evaluation (GRADE) criteria and non-GRADE methodology to provide guidance on screening among groups of patients at higher risk of PDAC, including those with Peutz-Jeghers syndrome (PJS), familial atypical multiple mole melanoma (FAMMM), ataxia-telangiectasia mutated gene, Lynch syndrome, hereditary pancreatitis, familial pancreatic cancer kindreds with one or more first-degree relatives with PDAC, and other genetic variants, including BRCA1 and BRCA2.
The analysis, provided in a paired manuscript (Gastrointest Endosc. Published online Feb 16, 2022. doi: 10.1016/j.gie.2021.12.002), demonstrated cumulative screening yields of 3.1% for high-risk lesions and 2.1% for resectable and borderline-resectable lesions. Confirmation of this resectability status was 60% at surgery versus 20% among clinically symptomatic cancer. The potential harm of low-yield surgery that does not identify high-risk lesions was not insignificant at 46.6%.
- The panel suggests annual screening for PDAC among all the listed genetic susceptibility traits, each based upon limited literature rated as low or very low quality. Endoscopic ultrasound (EUS) and magnetic resonance imaging are both acceptable screening modalities, with EUS preferred for the initial screening, especially among the highest-risk groups (PJS, FAMMM) and when EUS is combined with upper intestinal screening (Lynch syndrome and PJS) when contraindications to anesthesia and endoscopy are not present.
- Recommended starting ages for screening vary by risk factor, with most starting at age 50 years or 10 years younger than the youngest age of onset in a relative with PDAC, but earlier for PJS (age 35 years or 10 years younger), FAMMM (age 40 years or 10 years younger), and autosomal-dominant hereditary pancreatitis (age 40 years).
- New guidance from this panel includes the recommendation for all patients with the BRCA1 or BRCA2 genetic variant to undergo screening, regardless of prior family history.
- All screening decisions should be made in the context of careful discussions regarding harms and benefits, patient preferences, and local expertise.