title: The diagnostic pathway for solid pancreatic neoplasms: are we applying too many tests?
abstract: BACKGROUND
  The single best diagnostic and staging test for pancreatic cancer remains a contrast-enhanced computed tomography scan. It is frequently the only imaging test required before surgical resection for solid pancreatic lesions. Unfortunately, many patients undergo additional testing that often delays definitive care.
  
  
  METHODS
  A retrospective review of all patients with solid pancreatic lesions concerning for adenocarcinoma referred to a high volume Hepato-Pancreato-Biliary (HPB) service over 4 y (2008-2012) was completed. The time intervals between the initial imaging test and both consultation with HPB surgery and operative intervention, as well as the number of additional tests, were evaluated. Standard statistical methodology was used (P < 0.05).
  
  
  RESULTS
  Among 130 patients with solid pancreatic lesions, the index imaging modality was ultrasonography and computed tomography for 75 (58%) and 52 (40%), respectively. Patients underwent a mean of 1.3 diagnostic tests after the index study and before consultation with HPB surgery (range: 0-5). There was a significant increase in time to HPB consultation and operative intervention with an increasing number of interval imaging tests. The mean time to surgical consultation and operation if 0 interval diagnostic tests were performed was 15.9 and 45.4 d, respectively. If four interval tests were conducted, the mean was 69.4 and 122.6 d, respectively. Sixty-two patients (48%) were initially referred to a nonsurgical service. The mean time to surgical consultation and operation if an intervening referral occurred was 36.6 and 66.8 d, respectively. This compares to 19.8 and 48.1 d, respectively, in cases of direct referral to an HPB surgeon. The mean number of diagnostic tests performed before HPB consultation if a nonsurgical referral occurred was 2.1 (versus 0.7 if direct HPB surgeon referral).
  
  
  CONCLUSIONS
  Despite a relatively simple algorithm for the investigation of solid pancreatic lesions, considerable heterogeneity remains in how these patients are evaluated before referral to HPB surgery. As the number of investigations increases after the index imaging test, there is increasing delay to both surgical consultation and definitive intervention. Education is required to expedite care and mitigate excess diagnostic tests.
authors.affiliation: Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.
authors.forename: Michael R
authors.initials: MR
authors.lastname: Driedger
authors.affiliation: Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.
authors.forename: Elijah
authors.initials: E
authors.lastname: Dixon
authors.affiliation: Department of Medicine, Cumming School of Medicine, University of Calgary, Calgary, Canada.
authors.forename: Rachid
authors.initials: R
authors.lastname: Mohamed
authors.affiliation: Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.
authors.forename: Francis R
authors.initials: FR
authors.lastname: Sutherland
authors.affiliation: Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada.
authors.forename: Oliver F
authors.initials: OF
authors.lastname: Bathe
authors.affiliation: Department of Surgery, Cumming School of Medicine, University of Calgary, Calgary, Canada. Electronic address: ball.chad@gmail.com.
authors.forename: Chad G
authors.initials: CG
authors.lastname: Ball
mesh_terms: D000230:Adenocarcinoma / Q000175:diagnosis* / Q000601:surgery; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D000416:Alberta; D057210:Delayed Diagnosis / Q000706:statistics & numerical data*; D005260:Female; D006801:Humans; D008297:Male; D008875:Middle Aged; D010190:Pancreatic Neoplasms / Q000175:diagnosis* / Q000601:surgery; D010818:Practice Patterns, Physicians' / Q000706:statistics & numerical data*; D012017:Referral and Consultation / Q000706:statistics & numerical data*; D012189:Retrospective Studies; D014057:Tomography, X-Ray Computed / Q000706:statistics & numerical data; D019564:Unnecessary Procedures / Q000706:statistics & numerical data*
keywords: Pancreatic cancer; Unnecessary testing