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ASGE guideline on screening for pancreatic cancer in individuals with genetic susceptibility: summary and recommendations

24.06.2022
This guideline document was prepared by the Standards of Practice Committee of the American Society for Gastrointestinal Endoscopy using the best available scientific evidence and considering a multitude of variables including, but not limited to, adverse events, patients’ values, and cost implications. The purpose of these guidelines is to provide best practice recommendations that may help standardize patient care, improve patient outcomes, and reduce variability in practice. We recognize that clinical decision-making is complex. Guidelines, therefore, are not a substitute for a clinician’s judgment. Such judgments may, at times, seem contradictory to our guidance because of many factors that are impossible to fully consider by guideline developers. Any clinical decisions should be based on the clinician’s experience, local expertise, resource availability, and patient values and preferences. This document is not a rule and should not be construed as establishing a legal standard of care or as encouraging, advocating for, mandating, or discouraging any particular treatment. Our guidelines should not be used in support of medical complaints, legal proceedings, and/or litigation because they were not designed for this purpose.
Pancreatic cancer is a rare but lethal cancer with a lifetime incidence of approximately 1.6%, and 5-year survival of 10%.
 Pancreatic cancer accounts for 3% of all newly diagnosed cancers and 8% of all cancer-related deaths in the United States in 2020,
 and the incidence is anticipated to rise over the next decade.
 Biologically aggressive behavior, advanced stage at the time of diagnosis, and poor response to oncologic therapies have been proposed as reasons for dismal outcomes in pancreatic cancer.

Diagnosis at earlier stages of disease is associated with improved survival, with 93% 10-year survival among stage 0 cancers and 34% to 39% 5-year survival among stage I cancers.
 However, by the time patients develop symptoms, almost 80% have advanced disease that is inoperable.
 In 2019, the U.S. Preventive Services Task Force reaffirmed their earlier guidelines by continuing to recommend against screening for pancreatic cancer in average-risk adults.
 This decision was based in part on the low incidence of pancreatic cancer in the general population. Importantly, the U.S. Preventive Services Task Force specifically stated that those recommendations did not apply to high-risk populations because of inherited genetic susceptibility. Although other guidelines have provided recommendations for individuals with genetic susceptibility, those guidelines have relied primarily on consensus of expert opinion.

The aim of this American Society for Gastrointestinal Endoscopy (ASGE) guideline is to provide evidence-based recommendations on screening for pancreatic cancer in individuals with genetic susceptibility. Although pathogenic germline variants in several genes have been associated with increased risk for pancreatic cancer, these guidelines focus on BRCA1 and BRCA2 because of their higher prevalence in the population.

 Familial pancreatic cancer (FPC) kindreds were defined as kindreds containing at least a pair of first-degree relatives with pancreatic cancer without an association with a known hereditary cancer syndrome.
Modeling studies strongly suggest autosomal-dominant inheritance of a rare allele as the likely etiology.
 Furthermore, most pancreatic cancer screening studies included those with FPC syndrome, and therefore we made screening recommendations for these individuals. Recommendations made in these guidelines should be used in the context of the individual patient and clinical setting, such that the ultimate decision regarding pancreatic cancer screening should be made with consideration of patient values, preferences, and availability of local expertise.

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