The diagnosis of PC carries a grim prognosis and usually results in rapid demise and death regardless of whether the tumor develops sporadically or as part of an inherited syndrome. At-risk patients vary in terms of their cancer risk and their disease's mechanisms, clinical presentation, biological behavior, and imaging characteristics. We must recognize the differences among patient cohorts and not apply data uniformly among these groups. Available data suggest that screening has the potential to detect pancreatic neoplastic precursors. Screening also detects many indeterminate neoplastic-type lesions that are often benign and of no clinical consequence, but may represent true neoplastic precursors for which the appropriate therapy is unclear. This uncertainty results largely from our lack of understanding regarding the natural history of diminutive precursor lesions. Some argue that resection of diminutive PanINs and IPMNs provides justification for screening. However, we must be cautious and not so freely accept this stance given the frequency and uncertain significance of these minute findings that in a general population would otherwise be observed or ignored. These misdiagnosed neoplastic-type lesions are detected at a rate several fold greater than the lifetime cancer risk. The Johns Hopkins group has led the effort to evaluate new and improved methods for screening high-risk patients. Continued work is necessary to provide quality care in a safe manner that allows improved patient outcomes. Until large, multicenter trials have adequately addressed remaining issues, routine screening cannot be broadly advocated. At the conclusion of our debate and this editorial, I am left agreeing with the stance taken by Dr Canto and others who favor screening. I do so cautiously and with great trepidation. My patients are carefully and thoroughly counseled (including formal genetic counseling) as to the benefits and risks associated with screening, and published data are reviewed. After doing so, many patients have questioned why screening is even offered or allowed. Some realize that screening may place them at greater risk for inaccurate diagnosis and unnecessary intervention than for detection of a clinically significant neoplasia that may be resected for cure. Most simply remain confused as to the best management strategy. Fear and anxiety lead most patients to undergo screening. Greater anxiety often ensues after discovery of indeterminate lesions. Dr Canto and colleagues reported that high-risk patients believed that their LTR of PC was 91% rather than the true rate of about 5% to 20%. This argues for improved education to help patients with the dif.cult decisions they face. We all welcome the day when screening of high-risk kindreds is more clearly directed by knowledge and science. We look forward to working with Dr Canto to reach these mutual goals.
ASJC Scopus subject areas
- Internal Medicine
- Endocrinology, Diabetes and Metabolism