New pancreatic cancer diagnostic aid released

Tim Robertson

5/07/2022 6:04:43 PM

The tool is designed to help GPs identify patients that should undergo investigation, as well as recommend initial diagnostic pathways.

GP looking at new diagnostic tool.
The tool aims to limit the number of consultations in primary care and reduce the time to diagnosis for people with pancreatic cancer.

Pancreatic cancer has the highest mortality rate among all main cancer types and is the fourth leading cause of cancer death in Australia.
It can also be frustratingly difficult to diagnose, Professor Rachel Neale from QIMR Berghofer told newsGP.
‘The symptoms of pancreatic cancer are often very non-specific and mostly an indicator of something less nasty, like irritable bowel or reflux,’ she said.
‘It is incredibly hard for GPs to decide which patients have got something concerning versus those patients who have got something far more benign and far more common.’ 
To assist practitioners, Professor Neale led the development of a newly released pancreatic cancer tool, which presents individual or combinations of signs, symptoms and risk factors in a way that helps indicate the suggested urgency of investigation.
‘We wanted to devise a set of guidelines that addressed the issue in a qualitative way that respected GPs ability to understand their patients and talk to them,’ Professor Neale said.  
‘One of our concerns was that if you give a quantitative number – like, the probability that this person has pancreatic cancer is, say, 20% – at what probability do you decide to do something about that? And how do you communicate that to a patient?
‘There are these probability prediction models and they don’t take into account things like the nature of the abdominal pain or if someone’s lost weight and whether that may be because they have changed their medications or something like that.
‘We really wanted to provide support for GPs to help guide them and consider when patients should go for management.’
The tool is divided into three tiers, depending on the likelihood of pancreatic cancer.
It describes clusters of symptoms and risk factors that should prompt urgent investigation and referral to specialist care, and clusters where other potential causes should be eliminated prior to investigations for pancreatic cancer.
The tool aims to limit the number of consultations in primary care and reduce the time to diagnosis for people with pancreatic cancer, while avoiding over-investigation.
Tier 1 includes five clinical presentation and risk factor clusters that indicate the need for urgent investigation of the pancreas. These include:

  • Pancreatic-type epigastric pain
  • Jaundice
  • Steatorrhea
  • Weight loss, plus any of the following:
    • Non-musculoskeletal upper back pain
    • Non-specific abdominal pain
    • Nausea
    • Changed bowel habits
  • New-onset or pre-existing but newly unstable diabetes mellitus, plus any of the following:
    • Family history of pancreatic cancer
    • History of pancreatitis
    • Non-specific abdominal pain
    • Non-musculoskeletal upper back pain
A further five clusters are included as Tier 2. It is recommended that patients presenting with these signs and symptoms should undergo a trial of management or investigations to eliminate other causes over a limited time period. If these do not result in a definitive diagnosis within the recommended time period, then investigative tests of the pancreas should be ordered.
Tier 3 includes a list of non-specific signs, symptoms and risk factors that indicate the need to consider pancreatic cancer as a potential diagnosis, but without specific recommendations for investigation.
‘Given that GPs work in a very time precious environment, and they are dealing with so much in such a short span of time, having tools or checklists or flowcharts really helps us when we are faced with suspicious symptoms,’ Dr Anita Sharma, a member of the RACGP Education Committee told newsGP.
‘This tool provides a very clearcut pathway of what symptoms warrant urgent looking into.’
A modified Delphi process, including a series of three surveys, was undertaken to ascertain clinical expert opinion on which combinations of signs, symptoms and risk factors should be included in a tool.
A focus group of 12 clinicians – five gastroenterologists, two hepatobiliary surgeons, four GPs and one oncologist – then met to discuss the results and how to use them to guide the final development of the tool.
They reached consensus on the signs, symptoms and risk factors, and combinations of these to include in the tool, as well as the recommended initial diagnostic pathways for each.
Diabetes is illustrative of how the tool aims to guide GPs in considering combinations of symptoms, explains Professor Neale.
‘If you have got new onset or pre-existing but newly unstable diabetes, generally what would happen is that you would do a trial of treatment – you would just assume they have normal diabetes, which happens,’ she said.  
‘But we are saying that if you have also got a family history of pancreatic cancer or a history of pancreatitis or abdominal pain or back pain, actually that is probably a red flag for investigating the pancreas.
‘But if you have got existing diabetes that becomes unstable but you don’t have any of those other things, then we’d be saying do a trial of management for six weeks or so and if that diabetes is still unstable and the person is aged over 40 years, then you would send them off for investigations of their pancreas.’
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Dr Manimala Chacko Alexander   6/07/2022 8:05:54 PM

In my opinion surgically curable pancreatic cancer is more likely to be diagnosed accidentally.I had a patient with epigastric pain radiating to the back without any weight loss or loss of appetite of one month duration CT scan showed pancreatic lesion and was hoped suitable for surgery but found had superior mesenteric artery involvement. He had chemotherapy but unfortunately died within two years.I had another patient who had resection of pancreatic cancer and was felt he had no metastatic disease. Unfortunately he also did not survive three years.