A clinical and economic evaluation of endoscopic ultrasound for patients at risk for familial pancreatic adenocarcinoma.
OBJECTIVE
Approximately 10% of pancreatic adenocarcinoma is familial. Approximately 50% of 1st-degree relatives (FDRs) have endoscopic ultrasound (EUS) findings of chronic pancreatitis. We modeled the natural history of these patients to compare 4 management strategies.


METHODS
We performed a systematic review, and created a Markov model for 45-year-old male FDRs, with findings of chronic pancreatitis on screening EUS. We compared 4 strategies: doing nothing, prophylactic total pancreatectomy (PTP), annual surveillance by EUS, and annual surveillance with EUS and fine needle aspiration (EUS/FNA). Outcomes incorporated mortality, quality of life, procedural complications, and costs.


RESULTS
In the Do Nothing strategy, the lifetime risk of cancer was 20%. Doing nothing provided the greatest remaining years of life, the lowest cost, and the greatest remaining quality-adjusted life years (QALYs). PTP provided the fewest remaining years of life, and the fewest remaining QALYs. Screening with EUS provided nearly identical results to PTP, and screening with EUS/FNA provided intermediate results between PTP and doing nothing. PTP provided the longest life expectancy if the lifetime risk of pancreatic cancer was at least 46%, and provided the most QALYs if the risk was at least 68%.


CONCLUSIONS
FDRs from familial pancreatic cancer kindreds, who have EUS findings of chronic pancreatitis, have increased risk for cancer, but their precise risk is unknown. Without the ability to further quantify that risk, the most effective strategy is to do nothing.
Rubenstein
Joel H
JH
Ann Arbor Veterans Affairs Medical Center, Ann Arbor, MI 48105, USA. jhr@umich.edu
Scheiman
James M
JM
Anderson
Michelle A
MA
D000230:Adenocarcinoma / Q000000981:diagnostic imaging* / Q000235:genetics; D044963:Biopsy, Fine-Needle / Q000191:economics; D003661:Decision Support Techniques; D019160:Endosonography / Q000191:economics*; D020022:Genetic Predisposition to Disease; D017048:Health Care Costs; D006801:Humans; D008297:Male; D008390:Markov Chains; D008875:Middle Aged; D010179:Pancreas / Q000000981:diagnostic imaging; D010180:Pancreatectomy / Q000191:economics; D010190:Pancreatic Neoplasms / Q000000981:diagnostic imaging* / Q000235:genetics; D050500:Pancreatitis, Chronic / Q000150:complications* / Q000628:therapy; D011788:Quality of Life; D012306:Risk