archived

Final Recommendation Statement

Pancreatic Cancer: Screening, 1996

January 01, 1996

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

This Recommendation is out of date

It has been replaced by the following: Pancreatic Cancer: Screening (2019)

Recommendation Summary

Population Recommendation Grade
Asymptomatic persons Routine screening for pancreatic cancer in asymptomatic persons, using abdominal palpation, ultrasonography, or serologic markers, is not recommended. D

Full Recommendation:

Recommendations made by the USPSTF are independent of the U.S. government. They should not be construed as an official position of the Agency for Healthcare Research and Quality or the U.S. Department of Health and Human Services.

Expand All

Cancer of the pancreas is the fifth leading cause of cancer deaths in the U.S., accounting for an estimated 27,000 deaths in 1995 (8.4 deaths/100,000 persons).[[1,1a]] Worldwide, the age-adjusted incidence and mortality of pancreatic cancer have been increasing since the 1930s,2,3 although in the U.S. these rates have declined since the early 1970s.[[1,1a] Incidence rates may be overestimated, because an important proportion of pancreatic cancer diagnoses (as many as half in some studies) are not histologically confirmed.4 Pancreatic cancer is more common in men, blacks, cigarette smokers, and older persons (the majority of cases being diagnosed between ages 65 and 79).1,2,3,5 The risk of pancreatic cancer is increased in patients with diabetes, including those with long-standing (>=5 years) diabetes. 5a Familial aggregations of pancreatic cancer are rare but have been described.2,6

Since initial symptoms are usually nonspecific (e.g., abdominal pain and weight loss) and are frequently disregarded, some 80-90% of patients have regional and distant metastases by the time they are diagnosed.5,7 Only 3% of the 24,000 patients annually diagnosed with pancreatic cancer live more than 5 years after diagnosis.[[1,1a] Of pancreatic adenocarcinomas, which account for more than 90% of all pancreatic neoplasms,5 only about 4-16% are resectable at diagnosis,4,8-12 and the 5-year survival rate is less than 1%.7 In addition, 5-year survival does not indicate cure, since further decrements in survival occur after 5 years.13,14 

Return to Table of Contents

Adenocarcinoma is the principal form of pancreatic neoplasm for which screening has been considered in this chapter, "pancreatic cancer" refers to adenocarcinoma. There are no reliable screening tests for detecting pancreatic cancer in asymptomatic persons. The deep anatomic location of the pancreas makes detection of small localized tumors unlikely during the routine abdominal examination. Even in patients with confirmed pancreatic cancer, an abdominal mass is palpable in only 15-25% of cases.4,5,15,16

Imaging procedures such as magnetic resonance imaging and computed tomography are too costly to use as routine screening tests, while more accurate tests such as endoscopic retrograde cholangiopancreatography and endoscopic ultrasound are inappropriate for screening asymptomatic patients due to their invasiveness.17,18 Abdominal ultrasonography is a noninvasive screening test, but there is little information on the efficacy of abdominal ultrasound as a screening test for pancreatic cancer in asymptomatic persons. In symptomatic patients with suspected disease it has a reported sensitivity of 40-98% and a specificity as high as 90-94%.15,19,20 Conventional ultrasonography is limited by visualization difficulties in the presence of bowel gas or obesity and by its range of resolution (2-3 cm).7,18,20 Even tumors <2 cm in diameter are frequently associated with metastatic disease,8,11,21 thus limiting the ability of ultrasound to detect early disease.

Most persons with pancreatic malignancy have elevated levels of certain serologic markers such as CA19-9, peanut agglutinin, pancreatic oncofetal antigen, DU-PAN-2, carcinoembryonic antigen, alpha-fetoprotein, CA-50, SPan-1, and tissue polypeptide antigen.22-25 None of these markers is, however, tumor specific or organ specific25 elevations of various serologic markers also occur in significant proportions of persons with benign gastrointestinal diseases or malignancies other than pancreatic cancer.17,22,24,25 Most of these markers have been studied exclusively in high-risk populations, such as symptomatic patients with suspected pancreatic cancer. CA19-9 has probably achieved the widest acceptance as a serodiagnostic test for pancreatic carcinoma in symptomatic patients, with an overall sensitivity of approximately 80% (68-93%) and specificity of 90% (73-100%) sensitivity was highest in patients with more advanced disease.23,24 Among healthy subjects, CA19-9 has good specificity (94-99%)26-28 but nevertheless generates a large proportion of false-positive results due to the very low prevalence of pancreatic cancer in the general population.29 A study of a mass screening of more than 10,000 asymptomatic persons for pancreatic cancer in Japan,30 using either ultrasonography alone or CA19-9 plus elastase-1, found the likelihood of pancreatic cancer given a positive screening test to be 0.5% only one of the four cancers discovered could be curably resected.

The predictive value of a positive test could be improved if a population at substantially higher risk could be identified. Diabetes mellitus in older adult patients might be useful as a marker for a population at high risk of having pancreatic cancer.3,31,32 Cohort studies have reported incidences of pancreatic cancer among diabetic patients ranging from 51 to 166/100,000 person-years. 5a Studies evaluating screening efficacy might therefore be warranted in this population. 

Return to Table of Contents

Evidence that early detection can lower morbidity or mortality from pancreatic cancer is not conclusive. The reported 5-year survival for localized disease based on 1983-1990 national data is only 9%, not substantially higher than the 5-year survival with regional (4%) and distant (2%) metastases.[[1a]] A comprehensive review of published reports on surgical resection of pancreatic cancer estimated an overall 5-year survival rate of 8% for small tumors without evidence of local or distant spread.8 In part, this low rate may reflect the fact that a proportion of patients with localized disease cannot be operated on because of concomitant medical problems, advanced age, or other reasons.10,11,13 Patients who have small localized tumors that are resected for attempted cure, which account for only 4-16% of the total, may have better 5-year survival rates (as high as 37-48% in the most experienced centers),8-13,21,33 although the designs of most studies of surgical outcome suffer from lead-time, length, and selection biases. The morbidity associated with surgical resection is high (15-53%), but perioperative mortality is now less than 7% in the hands of experienced surgeons.8,9,13,33,34

Reports on the effectiveness of adjuvant external beam and/or intraoperative radiotherapy in improving survival among curatively resected patients, using historical controls, have yielded inconsistent results.35-37 In one small randomized controlled trial,38 corroborated by a subsequent case series by the same authors,39 an adjuvant treatment program using combined radiation and chemotherapy following curative resection was associated with a significant median survival advantage of 9 months and a 5-year survival advantage of 14.5% in treated versus control cases however, the study was closed early due to poor subject accrual and it did not control for the substantially greater frequency of clinic visits by cases. Adverse effects of combined radiation and chemotherapy include leukopenia and gastrointestinal toxicity.38,40 Intraoperative radiotherapy frequently causes gastrointestinal bleeding, which may be life-threatening.37 Additional randomized controlled trials of adjuvant therapy are needed to confirm its effectiveness in improving survival in patients with early pancreatic carcinoma. New modalities being explored include immunotherapy41 and hormonal therapy.42 

Return to Table of Contents

Cigarette smoking has been consistently associated with a modestly increased risk of pancreatic cancer in numerous cohort and case-control studies of populations in the U.S., Canada, Europe, and Japan.3,43-46 A clear dose-response relationship has not been demonstrated, however, nor have the biologic mechanisms underlying this association been adequately delineated. Cohort and case-control studies suggest that former smokers have a decreased risk of pancreatic cancer compared with current smokers,43,44,47-49 but estimates of the duration of abstinence required to show a reduction in risk have varied from as few as 1-3 years to as many as 10-20 years, and some studies have found no risk reduction at all associated with smoking cessation.43,45 In addition, a number of these studies suffer from selection, misclassification, and other biases. Although the causal relationship between smoking and pancreatic cancer requires further study, counseling patients to discontinue smoking (see Chapter 54) is easily justified by its established efficacy in preventing other malignancies (e.g., lung cancer), coronary artery disease, and other serious disorders.

Several cohort studies and many population-based case-control studies have reported positive associations between pancreatic cancer and dietary factors such as meat, eggs, carbohydrates, refined sugar, cholesterol, fat, and total calorie intake, as well as negative (protective) associations with intake of vegetables and fruits.3,46,48,50-56 However, study results are inconsistent many studies suffer from selection, misclassification, and other biases and large numbers of comparisons make significance testing problematic. Further research to define nutritional risk factors for pancreatic cancer is therefore needed. Studies of the relationship between increased alcohol consumption and pancreatic cancer have yielded inconsistent results3,45-48,57,58 few have adequately assessed level and duration of intake, or evaluated the possibility of a link between alcohol, pancreatitis, and pancreatic cancer. Current epidemiologic evidence does not support an association between pancreatic cancer and coffee consumption.3,58,59 

Return to Table of Contents

No groups recommend routine screening for pancreatic cancer in asymptomatic persons. The Canadian Task Force on the Periodic Health Examination recommends against such screening.60

Return to Table of Contents

Given the lack of evidence for improved outcome with early detection of pancreatic cancer, the invasive nature of diagnostic tests likely to follow a positive screening test (e.g., endoscopic ultrasound, laparotomy), and the fact that most positive screening tests would be false positives, screening for pancreatic cancer cannot be recommended at this time. Primary prevention of pancreatic cancer may be possible through clinical efforts directed at the use of tobacco products. 

Return to Table of Contents

Routine screening for pancreatic cancer in asymptomatic persons, using abdominal palpation, ultrasonography, or serologic markers, is not recommended ("D" recommendation). All patients should be counseled regarding use of tobacco products (see Chapter 54). Counseling to reduce fat and cholesterol intake and to increase intake of fruits and vegetables may be recommended on other grounds (see Chapter 56).

Return to Table of Contents

The draft update of this chapter was prepared for the U.S. Preventive Services Task Force by Carolyn DiGuiseppi, MD, MPH. 

Return to Table of Contents

1. Wingo PA, Tong T, Bolden S. Cancer statistics, 1995. CA Cancer J Clin. 1995;45:8–30. [PubMed]
1A. Ries LAG, Miller BA, Hankey BF, et al, eds. SEER. cancer statistics review, 1973-1991: tables and graphs. Bethesda: National Cancer Institute. 1994;(NIH Publication no. 94-2789.)
2. Gordis L, Gold EB. Epidemiology of pancreatic cancer. World J Surg. 1984;8:808–821. [PubMed]
3. Boyle P, Hsieh C-C, Maisonneuve P, et al. Epidemiology of pancreas cancer (1988). Int J Pancreatol. 1989;5:327–346. [PubMed]
4. Gudjonsson B. Cancer of the pancreas: 50 years of surgery. Cancer. 1987;60:2284–2303. [PubMed]
5. Arnar D, Theodors A, Isaksson HJ, et al. Cancer of the pancreas in Iceland. An epidemiologic and clinical study, 1974-85. Scand J Gastroenterol. 1991:26:724–730. [PubMed]
5A. Everhart J, Wright D. Diabetes mellitus as a risk factor for pancreatic cancer: a meta-analysis. JAMA. 1995;273:1605–1609. [PubMed]
6. Lynch HT, Fitzsimmons ML, Smyrk TC, et al. Familial pancreatic cancer: clinicopathologic study of 18 nuclear families. Am J Gastroenterol. 1990;85:54–60. [PubMed]
7. Poston G, Williamson R. Causes, diagnosis, and management of exocrine pancreatic cancer. Compr Ther. 1990;16:36–42. [PubMed]
8. Russell RCG. Surgical resection for cancer of the pancreas. Baillieres Clin Gastroenterol. 1990;4:889–916. [PubMed]
9. Michelassi F, Erroi F, Dawson PJ, et al. Experience with 647 consecutive tumors of the duodenum, ampulla, head of the pancreas, and distal common bile duct. Ann Surg. 1989;210:544–556. [PMC free article] [PubMed]
10. Gall FP, Kessler H, Hermanek P. Surgical treatment of ductal pancreatic carcinoma. Eur J Surg Oncol. 1991;17:173–181. [PubMed]
11. Nix GA, Dubbelman C, Wilson JHP, et al. Prognostic implications of tumor diameter in carcinoma of the head of the pancreas. Cancer. 1991;67:529–535. [PubMed]
12. Bottger T, Zech J, Weber W, et al. Relevant factors in the prognosis of ductal pancreatic carcinoma. Acta Chir Scand. 1990;156:781–788. [PubMed]
13. Tsuchiya R, Tsunoda T, Ishida T, et al. Resection for cancer of the pancreas--the Japanese experience. Baillieres Clin Gastroenterol. 1990;4:931–939. [PubMed]
14. Livingston EH, Welton ML, Reber HA. Surgical treatment of pancreatic cancer. The United States experience. Int J Pancreatol. 1991;9:153–157. [PubMed]
15. Nordback I, Hyoty M, Auvinen O. Improved detection of cancer of the body or tail of the pancreas. Eur J Surg. 1991;157:33–37. [PubMed]
16. Ceuterick M, Gelin M, Rickaerr F, et al. Pancreaticoduodenal resection for pancreatic or periampullary tumors—a ten-year experience. Hepatogastroenterology. 1989;36:467–473. [PubMed]
17. Carter DC. Cancer of the pancreas. Gut. 1990;31:494–496. [PMC free article] [PubMed]
18. Grimm H, Maydeo A, Soehendra N. Endoluminal ultrasound for the diagnosis and staging of pancreatic cancer. Baillieres Clin Gastroenterol. 1990;4:869–888. [PubMed]
19. Wang TH, Lin JT, Chen DS, et al. Noninvasive diagnosis of advanced pancreatic cancer by real-time ultrasonography, carcinoembryonic antigen, and carbohydrate antigen 19-9. Pancreas. 1986;1:219–223. [PubMed]
20. DelMaschio A, Vanzulli A, Sironi S, et al. Pancreatic cancer versus chronic pancreatitis: diagnosis with CA 19-9 assessment, US, CT, and CT-guided fine-needle biopsy. Radiology. 1991;178:95–99. [PubMed]
21. Tsuchiya R, Nada T, Harada N, Miyamoto T, Tomioka T, Izawa K, et al. Collective review of small carcinomas of the pancreas. Ann Surg. 1986;203:77–81. [PMC free article] [PubMed]
22. Rhodes JM, Ching CK. Serum diagnostic tests for pancreatic cancer. Baillieres Clin Gastroenterol. 1990;4:833–853. [PubMed]
23. Steinberg W. The clinical utility of the CA 19-9 tumor-associated antigen. Am J Gastroenterol. 1990;85:350–355. [PubMed]
24. Satake K, Chung Y-S, Yokomatsu H, et al. A clinical evaluation of various tumor markers for the diagnosis of pancreatic cancer. Int J Pancreatol. 1990;7:25–36. [PubMed]
25. Satake K. Diagnosis of pancreatic cancer. Serological markers. Int J Pancreatol. 1991;9:93–98. [PubMed]
26. Del Villano BC, Brennan S, Brock P, et al. Radioimmunometric assay for a monoclonal antibody defined tumor marker, CA 19-9. Clin Chem. 1983;29:549–552. [PubMed]
27. Ritts RE Jr, Del Villano BC, Go VLW, et al. Initial clinical evaluation of an immunoradiometric assay for CA 19-9 using the NCI serum bank. Int J Cancer. 1984;33:339–445. [PubMed]
28. Fabris C, Del Favero G, Basso D, et al. Serum markers and clinical data in diagnosing pancreatic cancer: a contrastive approach. Am J Gastroenterol. 1988;83:549–553. [PubMed]
29. Frebourg T, Bercoff E, Manchon N, et al. The evaluation of CA 19-9 antigen level in the early detection of pancreatic cancer. A prospective study of 866 patients. Cancer. 1988;62:2287–2290. [PubMed]
30. Homma T, Tsuchiya R. The study of the mass screening of persons without symptoms and of the screening of outpatients with gastrointestinal complaints or icterus for pancreatic cancer in Japan, using CA 19-9 and elastase-1 or ultrasonography. Int J Pancreatol. 1991;9:119–124. [PubMed]
31. Rosa JA, Van Linda BM, Abourizk NN. New-onset diabetes mellitus as a harbinger of pancreatic carcinoma. A case report and literature review. J Clin Gastroenterol. 1989;11:211–215. [PubMed]
32. Ishikawa O, Ohhigashi H, Wada A, et al. Morphologic characteristics of pancreatic carcinoma with diabetes mellitus. Cancer. 1989;64:1107–1112. [PubMed]
33. Crist DW, Sitzmann JV, Cameron JL. Improved hospital morbidity, mortality, and survival after the Whipple procedure. Ann Surg. 1987;206:358–365. [PMC free article] [PubMed]
34. Trede M, Schwall G. The complications of pancreatectomy. Ann Surg. 1988;207:39–47. [PMC free article] [PubMed]
35. Hiraoka T. Extended radical resection of cancer of the pancreas with intraoperative radiotherapy. Baillieres Clin Gastroenterol. 1990;4:985–993. [PubMed]
36. Shibamoto Y, Manabe T, Baba N, et al. High dose, external beam and intraoperative radiotherapy in the treatment of resectable and unresectable pancreatic cancer. Int J Radiol Oncol Biol Phys. 1990;19:605–611. [PubMed]
37. Heijmans JH, Hoekstra HJ, Mehta DM. Is adjuvant intra-operative radiotherapy (IORT) for resectable and unresectable pancreatic carcinoma worthwhile? Hepatogastroenterology. 1986; 1989;36:474–477. [PubMed]
38. Kalser MH, Ellenberg SS. Pancreatic cancer: adjuvant combined radiation and chemotherapy following curative resection. Arch Surg. 1985;120:899–903. [PubMed]
39. Gastrointestinal Tumor Study Group. Further evidence of effective adjuvant combined radiation and chemotherapy following curative resection of pancreatic cancer. Cancer. 1987;59:2006–2010. [PubMed]
40. Arbuck SG. Chemotherapy for pancreatic cancer. Baillieres Clin Gastroenterol. 1990;4:953–968. [PubMed]
41. Buchler M, Friess H, Malfertheiner P, et al. Studies of pancreatic cancer utilizing monoclonal antibodies. Int J Pancreatol. 1990;7:151–157. [PubMed]
42. Andren-Sandberg A, Johansson J Influence of sex hormones on pancreatic cancer. Int J Pancreatol. 1990;7:167–176. [PubMed]
43. Office on Smoking and Health, Centers for Disease Control and Prevention. The health benefits of smoking cessation. Atlanta: Department of Health and Human Services. 1990:155–159.
44. Howe GR, Jain M, Burch JD, Miller AB. Cigarette smoking and cancer of the pancreas: evidence from a population-based case-control study in Toronto, Canada. Int J Cancer. 1991;47:323–328. [PubMed]
45. Ghadirian P, Simard A, Baillargeon J. Tobacco, alcohol, and coffee and cancer of the pancreas. A population-based, case-control study in Quebec, Canada. Cancer. 1991;67:2664–2670. [PubMed]
46. Hirayama T. Epidemiology of pancreatic cancer in Japan. Jpn J Clin Oncol. 1989;19:208–215. [PubMed]
47. Farrow DC, Davis S. Risk of pancreatic cancer in relation to medical history and the use of tobacco, alcohol and coffee. Int J Cancer. 1990;45:816–820. [PubMed]
48. Olsen GW, Mandel JS, Gibson RW, et al. A case-control study of pancreatic cancer and cigarettes, alcohol, coffee and diet. Am J Public Health. 1989;79:1016–1019. [PMC free article] [PubMed]
49. Bueno de Mesquita HB, Maisonneuve P, Moerman CJ, et al. Life-time history of smoking and exocrine carcinoma of the pancreas: a population-based case-control study in the Netherlands. Int J Cancer. 1991;49:816–822. [PubMed]
50. Bueno de Mesquita HB, Moerman CJ, Runia S, Maisonneuve P. Are energy and energy-providing nutrients related to exocrine carcinoma of the pancreas? Int J Cancer. 1990;46:435–444. [PubMed]
51. Farrow DC, Davis S. Diet and the risk of pancreatic cancer in men. Am J Epidemiol. 1990;132:423–431. [PubMed]
52. Baghurst PA, McMichael AJ, Slavotinek AH, et al. A case-control study of diet and cancer of the pancreas. Am J Epidemiol. 1991;134:167–179. [PubMed]
53. Bueno de Mesquita HB, Maisonneuve P, Runia S, Moerman CJ. Intake of foods and nutrients and cancer of the exocrine pancreas: a population-based case-control study in the Netherlands. Int J Cancer. 1991;48:540–549. [PubMed]
54. Ghadirian P, Simard A, Baillargeon, et al. Nutritional factors and pancreatic cancer in the francophone community in Montreal, Canada. Int J Cancer. 1991;47:1–6. [PubMed]
55. Zatonski W, Przewozniak K, Howe GR, et al. Nutritional factors and pancreatic cancer: a case-control study from south-west Poland. Int J Cancer. 1991;48:390–394. [PubMed]
56. Howe GR, Jain M, Miller AB. Dietary factors and risk of pancreatic cancer: results of a Canadian population-based case-control study. Int J Cancer. 1990;45:604–608. [PubMed]
57. Cuzick J, Babiker AG. Pancreatic cancer, alcohol, diabetes mellitus and gall-bladder disease. Int J Cancer. 1989;43:415–421. [PubMed]
58. Jain M, Howe GR, St. Louis P, et al. Coffee and alcohol as determinants of risk of pancreas cancer: a case-control study from Toronto. Int J Cancer. 1991;47:384–389. [PubMed]
59. Gordis L. Consumption of methylxanthine-containing beverages and risk of pancreatic cancer. Cancer Lett. 1990;52:1–12. [PubMed]
60. Canadian Task Force on the Periodic Health Examination. Canadian guide to clinical preventive health care. Ottawa: Canada Communication Group. 1994:862–869.

Return to Table of Contents