New American Gastroenterological Association guidelines recommend significant change in clinical practice
A new guideline1 from the American Gastroenterological Association (AGA) changes clinical practice by recommending longer surveillance periods for patients with asymptomatic pancreatic cysts and new criteria that limits surgery to those who will receive the most benefit.
It is estimated that more than 15 percent of patients who visit a doctor's office or hospital outpatient department will receive an MRI or other type of scan,2 and of those, about 15 percent will have incidental pancreatic cysts. Once detected, these cysts trigger anxiety for patients and physicians. However, the risk of malignancy for pancreatic cysts is low -- most of the patients who undergo surgery, which comes with risk, have a benign cyst. The new guideline, published in Gastroenterology, the official journal of the AGA Institute, helps physicians know how to appropriately monitor patients with cysts.
"Pancreatic cysts are a common occurrence that increases with age, but, based on the best available evidence, the risk of developing into cancer is low," according to Paul Moayyedi, MD, PhD, AGAF, an author of the guideline, the technical review3 and an accompanying commentary,4 from the division of gastroenterology Hamilton Health Sciences, McMaster University, Ontario, CN. "This AGA guideline represents a significant change in current clinical practice for managing pancreatic cysts, because they advocate less frequent follow up and a higher threshold before offering endoscopic ultrasound and/or surgery. Consistent use of the recommendations should decrease inadvertent harm to patients and reduce the costs of health-care delivery."
The AGA guideline for asymptomatic pancreatic cysts is different from previously published guidelines is several ways.
- The new guideline suggests a two-year screening interval for cysts of any size and stopping surveillance after five years if there is no change.
- The new guideline recommends surgery only if more than one concerning feature on MRI is confirmed by endoscopic ultrasound (EUS) and only in centers with high volumes of pancreatic surgery.
- The new guideline recommends discontinuing surveillance after surgery if no invasive cancer or dysplasia is identified.
AGA developed the guideline using Grading of Recommendations Assessment, Development and Evaluation (GRADE) methodology and best practices as outlined by the Institute of Medicine. All of the evidence related to the management of pancreatic cysts is graded as very low quality. However, given the serious outcome of a minority of pancreatic cysts and the need for clinical guidance on how to manage this complex problem, it is important to develop guidelines using the limited evidence that is available.
"Other guidelines may offer different recommendations, but the evidence would not support the certainty of their alternative positions. There is simply not enough evidence in current literature to have even a modest degree of certainty of the benefits of surveillance," writes David S. Weinberg, MD, MSc, AGAF, chair of the AGA Guidelines Committee, and colleagues in an editorial that accompanies the guideline. "This lack of evidence has been seen by some as reason to be as aggressive as possible so that no malignancy is missed. However, this approach will also expose many patients to risk and, on occasion, unnecessary interventions."
Review of this guideline, plus the associated technical review, clinical decision support tool and accompanying commentaries will facilitate effective shared decision making with patients regarding risk and surveillance of pancreatic cysts.
- American Gastroenterological Association Institute Guideline on the Diagnosis and Management of Pancreatic Cysts
- American Gastroenterological Association Institute Technical Review on the Diagnosis and Management of Pancreatic Cysts
- Management of Asymptomatic Neoplastic Pancreatic Cysts: Clinical Decision Support Tool
- Management of Pancreatic Cysts in an Evidence-Based World
- Managing Pancreatic Cysts: Less is More?
- Management of Pancreatic Cysts: The Evidence is Not Here Yet