TOPLINE

In a study at one large US healthcare system, use of invasive testing for pancreatic cyst surveillance declined markedly over 16 years. There was no signal that de-escalation affected the stage at diagnosis or overall survival among patients who developed cancer.

METHODOLOGY

• Pancreatic cystic neoplasms are a clinical challenge because they carry variable risk for progression to cancer. Since 2012, professional society guidelines have increasingly emphasized risk stratification and de-escalation of invasive testing for patients with pancreatic cysts that lack high-risk features.
• Researchers at Kaiser Permanente Southern California conducted a retrospective cohort study to see how their system’s surveillance strategies have shifted over time and whether there were corresponding changes in pancreatic cancer diagnostic stage or survival.
• They included 13,258 patients diagnosed with pancreatic cysts between 2006 and 2022. The calendar year of diagnosis was grouped into three practice eras: pre-guideline (2006-2012), updated guidance (2013-2017), and contemporary practice (2018-2022), reflecting shifts following major guideline implementations.
• Primary outcomes included pancreatic cancer incidence, stage at diagnosis, and overall survival. Surveillance practices were assessed using procedural codes to identify cross-sectional imaging, endoscopic ultrasound, and pancreatic surgery.

TAKEAWAY

• Over the study period, CT was the most commonly used surveillance strategy, with MRI use rising steadily after 2013. In contrast, the rate of endoscopic ultrasound use dropped over time to below 2% by 2022. Surgery also declined and was rarely used in the contemporary practice period.
• During a median follow-up of 3 years, 149 patients (1.1%) were diagnosed with pancreatic cancer, corresponding to an incidence rate of 279.6 per 100,000 person-years, with a cumulative incidence at 10 years of 0.020.
• At diagnosis, 34.9% of patients had in situ or localized disease, 29.5% had regional disease, and 31.5% had metastatic disease, with no significant differences in early- or late-stage pancreatic cancer incidence across practice eras.
• Median overall survival among patients diagnosed with pancreatic cancer was 10 months (IQR, 2-32 months), with no significant difference in survival across practice eras (log-rank P = .30). In multivariable Cox regression, the practice era was not associated with cancer survival (years, 2013-2018: hazard ratio [HR], 0.84; years, 2019-2022: HR, 0.91).

IN PRACTICE

“[W]e observed substantial de-escalation of invasive testing with reductions in [endoscopic ultrasound] utilization and pancreatic surgery while stage at diagnosis and overall survival among patients who developed [pancreatic cancer] remained stable,” the study authors wrote. They added, however, that while the findings support the safety of contemporary surveillance strategies, the lack of improvement in survival among patients who developed cancer “underscores potential limitations of imaging-based risk stratification strategies.”

SOURCE

The study, led by Bechien U. Wu, MD, MPH, of Kaiser Permanente Southern California in Pasadena, was published online as a research letter in JAMA Network Open.

LIMITATIONS

The observational design prevents causal inferences about the relationship between surveillance de-escalation and cancer outcomes. The cohort was drawn from a single integrated healthcare system in Southern California, which may limit generalizability. The relatively short follow-up may not capture long-term outcomes or late-developing cancers.

DISCLOSURES

The study was funded by the Southern California Permanente Medical Group. The authors reported no relevant conflicts of interest.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.