Prevention

A Pioneering Pancreatic Cancer Risk Stratification Program

In a process known as risk stratification, practitioners at the Columbia University Pancreas Center take into consideration all evidence known to contribute to an individual's risk of developing pancreatic cancer. While the only known environmental risk factor for pancreas cancer is a past or present history of cigarette smoking, pancreas cancer can have a genetic basis, which investigators have made significant progress in understanding.

Pancreas Cancer Genetics

Gel electrophoresis, a process used in genetic analysis.

Inherited gene mutations play a role in up to 25% of cases, and there is a 2 to 125-fold increase in the risk of pancreas cancer in individuals with a family history of the disease. It is now known that at least five distinct cancer syndromes account for a number of inherited pancreatic cancers:

• Familial atypical multiple mole melanoma syndrome (FAMMM);
• Peutz-Jeghers syndrome (PJS);
• Early-onset familial breast cancer syndrome due to BRCA1 or BRCA2 mutations;
• Hereditary non-polyposis colorectal cancer syndrome(HNPCC); and
• Hereditary pancreatitis.

We analyze family medical history and provide genetic counseling and testing as appropriate. If a patient learns there is significant genetic risk, we provide guidance and recommend an ongoing testing regimen so that they may ultimately avoid the disease. Known as screening, this testing regimen involves imaging the pancreas with sensitive instruments to detect pre-cancerous abnormalities or small cancers that are surgically curable.

Pancreas Cancer Screening

The philosophy of cancer screening is based on the assumption that if one can identify pre-cancerous growths, the patient can be cured. In our center, management of high-risk patients begins with a detailed personal and family history, genetic counseling, and the option of genetic testing when indicated.

Screening begins approximately 10 years prior to the earliest age of onset of cancer in the family. Yearly screenings may be recommended as the individual approaches the age of onset of cancer in their family member.

Because many high-risk individuals will never develop pancreatic cancer, every effort is made to minimize the risk of the diagnostic procedures. Therefore, endoscopic ultrasound (EUS) is one of the preferred techniques. Patients who are found to have abnormalities should undergo magnetic resonance imaging (MRI/MRCP) or endoscopic retrograde cholangiopancreatography (ERCP), and close surveillance.

If screening tests are abnormal and a genetic abnormality is found, patients may be offered laparoscopic distal pancreatectomy, followed by total pancreatectomy in those patients found to have high-grade dysplasia, a pre-cancer condition, in the initially resected portion of the organ. We also suggest that patients with familial pancreatic cancer but no specific germline mutation be followed with EUS. Annual blood tests for CA 19-9, and banking of serum for future investigations is recommended.