Early Detection of Pancreatic Cancer

Abstract and Introduction

Abstract

Purpose of Review: Pancreatic cancer is the third leading cause of cancer death and with a dismal 5-year survival of 10%. Poor survival of pancreatic cancer is mostly due to its presentation and diagnosis at a late stage. The present article aims to update clinicians with recent progress in the field of early detection of pancreatic cancer.

Recent Findings: Pancreatic cancer screening is not recommended in the general population due to its low prevalence. In this review, we discuss high-risk groups for pancreatic cancer, including inherited predisposition to pancreatic cancer, new-onset diabetes, mucinous pancreatic cyst, and chronic pancreatitis. We discuss methods of enrichment of high-risk groups with clinical models using electronic health records and biomarkers. We also discuss improvements in imaging modalities and emerging role of machine learning and artificial intelligence in the field of imaging and biomarker to aid in early identification of pancreatic cancer.

Summary: There are still vast challenges in the field of early detection of pancreatic cancer. We need to develop noninvasive prediagnostic validated biomarkers for longitudinal surveillance of high-risk individuals and imaging modalities that can identify pancreatic cancer early.

Introduction

Pancreatic cancer is the third leading cause of cancer death and has a poor prognosis (5-year survival of 10%).^[1] Despite advances in medical science and technology, it is set to become the second leading cause of cancer death in the United States in a decade. Up to 85% of patients with pancreatic cancer get diagnosed with either locally advanced or distant metastatic disease.^[2] Dismal survival of pancreatic cancer is primarily attributed to a lack of early detection and a lack of effective treatment.^[3] To improve survival in pancreatic cancer, we need to identify pancreatic cancer at a resectable stage and develop better chemotherapy that are well tolerated in the elderly and prevent recurrence after curative surgical resection.^[4]

Early detection of pancreatic cancer is critical to improving survival. However, US Preventive and Screening Task Force recommended against the screening of pancreatic cancer in the general population.^[5] The most significant barrier for the screening of pancreatic cancer in the general population is its low incidence (12.9 per 100 000 per year) and low lifetime risk (1.6) of developing the disease.^[6,7] Even if a screening test is 99% sensitive and 99% specific, it will lead to unacceptably high rates of false-positive findings if applied to the general population.^[8] To avoid ramifications of over diagnosis during screening for early detection of pancreatic cancer, Chari^[9] has proposed a 3-step 2-sieve approach (DEF): first, define high-risk group; second, enrich the high-risk group; and third, find the lesion in the highly enriched cohort (Figure 1). The definition and enrichment of high-risk groups could be done using clinical criteria, biomarkers in tandem, algorithms applied to electronic health records (EHR), artificial intelligence-based approaches, or a combination of these strategies.

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Figure 1.

Approach to early detection of pancreatic cancer.

Defining High-risk Groups

The first sieve is to define population with higher (five to six folds and 5% lifetime risk) than average risk of pancreatic cancer. Inherited predisposition to pancreatic cancer, mucin-producing cystic lesions of the pancreas, new-onset diabetes (NOD) in individuals who are older than 50 years, and chronic pancreatitis^[10] are well defined high-risk groups.