NEWS & VIEWS DIAGNOSIS
A step closer to screening for curable pancreatic cancer? Marcia I. Canto and Ralph H. Hruban Refers to Harinck F. et al. A multicentre comparative prospective blinded analysis of EUS and MRI for screening of pancreatic cancer in high-risk individuals. Gut http://dx.doi.org/10.1136/gutjnl2014308-008
Early detection is the best opportunity to decrease cancer mortality rates. As such, a new study has made a head-to-head comparison of endoscopic ultrasonography and MRI for the detection of pancreatic lesions in high-risk asymptomatic individuals. Using multiple techniques for detection and screening could be the best approach. Pancreatic cancer is predicted to be the second leading cause of cancer death by the year 2030. 1 The advanced incurable stage at which most patients with pancreatic cancer present clinically is one of the primary reasons for the poor prognosis associated with this disease.2 By contrast, improvements in, and the growing use of, early detection tests are reducing the mortality rates of other types of cancer.3 The power of early detection is probably best illustrated with the many lives saved each year through colonoscopy. A substantial fraction of the reduction in colorectal cancer death rates in the USA can be attributed to early detection.3 One of the best hopes for decreasing mortality from pancreatic cancer is clearly the development of a sensitive and specific screening test to detect early curable disease. Reported in a new study in Gut, Harinck and colleagues 4 take an important step towards the creation of a rational approach to screening high-risk individuals for early, curable, pancreatic neoplasia. The authors report the results of a national multicentre study from the Dutch research group on pancreatic cancer surveillance in high-risk individuals, in which endoscopic ultra sonography (EUS) and MRI were used to screen 139 asymptomatic individuals with a high-risk of developing pancreatic cancer. Half of the individuals screened were at high risk because they carried a deleterious germ line alteration in a pancreatic cancer susceptibility gene (such as BRCA1, BRCA2, P16, STK11), and half had an increased risk of developing pancreatic cancer because they
had a strong family history of the disease. Several strengths stand out about the design of this study. First, the multi-institutional collaborative nature of the study allowed Harinck and colleagues to recruit a large number of patients, thereby increasing the validity and impact of the study. Second, both imaging modalities (EUS and MRI) were performed on all 139 individuals, allowing a head-to-head comparison of the techniques. Finally, the imaging studies were reviewed in a blinded fashion. One limitation of the study was the variability in the EUS equipment used for screening. Although this variability might reflect ‘real-world’ practice, the surprisingly low concordance between EUS and MRI for detecting cystic lesions (with better detection by MRI) was probably, at least in part, due to the use of radial, rather than linear, echoendoscopes. Hence, this study and an American randomized crossover study, also published this year, emphasize the importance of linear EUS for optimal detection of pancreatic lesions.5 Of the 139 asymptomatic individuals screened, nine (6%) were found to have at least one clinically relevant pancreatic lesion (defined as a solid lesion, or cystic lesions that meet revised Sendai criteria for resection or follow-up) at baseline screening.6 The clinically relevant lesions detected at baseline included two solid lesions (one of which was an 11 mm lymph node negative and margin negative pancreatic cancer), and nine cystic lesions ≥10 mm. Of interest, the two imaging techniques proved to be complementary. Specifically, EUS was
NATURE REVIEWS | GASTROENTEROLOGY & HEPATOLOGY © 2015 Macmillan Publishers Limited. All rights reserved
better at detecting small solid lesions and MRI was better at detecting cystic lesions. Remarkably, 135 of 139 individuals underwent a second surveillance 12 months later; during which 12 clinically relevant lesions were detected in eight (6%) individuals. Sadly, the patient who had a small pancreatic cancer detected on baseline screening was found to have metastatic disease. Taken together, these findings highlight the potential to detect clinically important lesions in asymptomatic individuals, the added value of performing both EUS and MRI, and the need to continue screening high-risk individuals after their baseline studies. The study also highlights some of the drawbacks of screening asymptomatic individuals for cancer. In addition to the clinically relevant lesions detected, a large number of clinically unimportant lesions were detected. In fact, 27% of the individuals screened had a clinically unimportant pancreatic lesion. The high proportion of individuals with detectable lesions is consistent with an American multicentre screening study, which demonstrated frequent detection of pancreatic lesions (42%). 7 In the Harinck et al. study, 4 the lesions detected included 58 cysts
A step closer to screening for curable pancreatic cancer? Marcia I. Canto and Ralph H. Hruban Refers to Harinck F. et al. A multicentre comparative prospective blinded analysis of EUS and MRI for screening of pancreatic cancer in high-risk individuals. Gut http://dx.doi.org/10.1136/gutjnl2014308-008
Early detection is the best opportunity to decrease cancer mortality rates. As such, a new study has made a head-to-head comparison of endoscopic ultrasonography and MRI for the detection of pancreatic lesions in high-risk asymptomatic individuals. Using multiple techniques for detection and screening could be the best approach. Pancreatic cancer is predicted to be the second leading cause of cancer death by the year 2030. 1 The advanced incurable stage at which most patients with pancreatic cancer present clinically is one of the primary reasons for the poor prognosis associated with this disease.2 By contrast, improvements in, and the growing use of, early detection tests are reducing the mortality rates of other types of cancer.3 The power of early detection is probably best illustrated with the many lives saved each year through colonoscopy. A substantial fraction of the reduction in colorectal cancer death rates in the USA can be attributed to early detection.3 One of the best hopes for decreasing mortality from pancreatic cancer is clearly the development of a sensitive and specific screening test to detect early curable disease. Reported in a new study in Gut, Harinck and colleagues 4 take an important step towards the creation of a rational approach to screening high-risk individuals for early, curable, pancreatic neoplasia. The authors report the results of a national multicentre study from the Dutch research group on pancreatic cancer surveillance in high-risk individuals, in which endoscopic ultra sonography (EUS) and MRI were used to screen 139 asymptomatic individuals with a high-risk of developing pancreatic cancer. Half of the individuals screened were at high risk because they carried a deleterious germ line alteration in a pancreatic cancer susceptibility gene (such as BRCA1, BRCA2, P16, STK11), and half had an increased risk of developing pancreatic cancer because they
had a strong family history of the disease. Several strengths stand out about the design of this study. First, the multi-institutional collaborative nature of the study allowed Harinck and colleagues to recruit a large number of patients, thereby increasing the validity and impact of the study. Second, both imaging modalities (EUS and MRI) were performed on all 139 individuals, allowing a head-to-head comparison of the techniques. Finally, the imaging studies were reviewed in a blinded fashion. One limitation of the study was the variability in the EUS equipment used for screening. Although this variability might reflect ‘real-world’ practice, the surprisingly low concordance between EUS and MRI for detecting cystic lesions (with better detection by MRI) was probably, at least in part, due to the use of radial, rather than linear, echoendoscopes. Hence, this study and an American randomized crossover study, also published this year, emphasize the importance of linear EUS for optimal detection of pancreatic lesions.5 Of the 139 asymptomatic individuals screened, nine (6%) were found to have at least one clinically relevant pancreatic lesion (defined as a solid lesion, or cystic lesions that meet revised Sendai criteria for resection or follow-up) at baseline screening.6 The clinically relevant lesions detected at baseline included two solid lesions (one of which was an 11 mm lymph node negative and margin negative pancreatic cancer), and nine cystic lesions ≥10 mm. Of interest, the two imaging techniques proved to be complementary. Specifically, EUS was
NATURE REVIEWS | GASTROENTEROLOGY & HEPATOLOGY © 2015 Macmillan Publishers Limited. All rights reserved
better at detecting small solid lesions and MRI was better at detecting cystic lesions. Remarkably, 135 of 139 individuals underwent a second surveillance 12 months later; during which 12 clinically relevant lesions were detected in eight (6%) individuals. Sadly, the patient who had a small pancreatic cancer detected on baseline screening was found to have metastatic disease. Taken together, these findings highlight the potential to detect clinically important lesions in asymptomatic individuals, the added value of performing both EUS and MRI, and the need to continue screening high-risk individuals after their baseline studies. The study also highlights some of the drawbacks of screening asymptomatic individuals for cancer. In addition to the clinically relevant lesions detected, a large number of clinically unimportant lesions were detected. In fact, 27% of the individuals screened had a clinically unimportant pancreatic lesion. The high proportion of individuals with detectable lesions is consistent with an American multicentre screening study, which demonstrated frequent detection of pancreatic lesions (42%). 7 In the Harinck et al. study, 4 the lesions detected included 58 cysts
