Preliminary Evaluation of Screening for Pancreatic Cancer in Patients With Inherited Genetic Risk

Study Overview
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Brief Summary
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The study is a prospective, observational study evaluating the utility of endoscopic ultrasound or MRI for the identification of preneoplastic and neoplastic pancreatic lesions in patients at high risk for pancreatic cancer, specifically those with BRCA1/2, ATM, or PALB2 mutations.

Detailed Description
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Endoscopic Ultrasound (EUS) has emerged as a critical component in the imaging, staging, and diagnosis of pancreatic cancer. Not only can EUS delineate a mass utilizing sonography through the wall of the stomach or duodenum, but it also can obtain diagnostic fine needle aspiration of suspicious lesions. Especially in patients with incomplete visualization of a mass on cross-sectional imaging, EUS can provide valuable anatomic information prior to surgical exploration. While several studies have demonstrated that EUS has high sensitivity and specificity in diagnosing pancreatic masses, head-to-head comparisons with established modalities like CT have been often methodologically flawed. In a meta-analysis, it was found that of 4 studies that assessed resectability, 2 showed no difference and 1 favored each modality. As such, estimates of accuracy for assessing preoperative resectability have also ranged in several studies from 63-93%. As such it has been recognized as an accepted modality for the evaluation of potential pancreatic malignany. While screening in the general population is not feasible given the low incidence of PDAC, screening in high risk cohorts may allow for early detection of resectable, and potentially curable tumors. Clinical outcome of patients with smaller, non-metastasized tumors have a significantly improved 5-year survival. Generally the current recommendation is that patients who are first degree relatives of patients with PDAC from a familial PDAC kindred with at least 2 affected first-degree relatives, patients with Peutz-Jegher's syndrome, and patients with CDKN2A/BRCA1/BRCA2/ATM/PALB2/Lynch mutations with a first or second degree relative with pancreatic cancer would qualify for screening in the context of the CAPS5 trial. However, very recent evidence in a large Canadian study of pancreatic cancer patients demonstrated germline carrier status for BRCA1/2, and ATM in their cohort was associated with first degree relatives with breast and colorectal cancer but not pancreatic cancer, suggesting that we may have to re-evaluate criteria for pancreatic cancer screening in this population. Thus, the risk of pancreatic cancer development in this cohort of patients would not be addressed by the CAPS5 protocol, but would uniquely be addressed in our proposed study. In terms of modality, interval, and age to start/stop, there remains debate but generally annual EUS/MRI has been utilized. Therefore, amongst patients with increased risk of pancreatic cancer, like those with BRCA1/2, ATM, or PALB2 mutations, the successful identification of early neoplastic/preneoplastic lesions of the pancreas would allow for timely intervention and improved survival in this cohort and thus would be of high clinical relevance. Thus we propose to utilize the unique cohort of increased risk patients followed at the University of Pennsylvania, to identify patients with BRCA1, BRCA2, ATM, or PALB2 mutations, regardless of family history of pancreatic cancer, and enroll them on an annual prospective pancreatic screening program. The hypothesis is that through early screening interventions, morbidity and mortality from this under-recognized malignancy in this high-risk patient population will be reduced.

Official Title
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Preliminary Evaluation of Screening for Pancreatic Cancer in Patients With Inherited Genetic Risk

Conditions
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Pancreatic Cancer

Intervention / Treatment
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* Other: surveillance endoscopic ultrasound or MRI of the abdomen


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria Age >= 18 Documented germline pathogenic or likely pathogenic BRCA1, BRCA2, ATM, or PALB2 mutation If no history of PDAC in a first or second degree relative, age >= 50 If there is a history of PDAC in a first or second degree relative, minimum age of eligibility is 10 years younger than the age of onset of the youngest relative with pancreatic cancer Exclusion Criteria • Pregnancy

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Arms and Interventions

| Intervention/Treatment |
| --- |
|Other: surveillance endoscopic ultrasound or MRI of the abdomen|The patients will be followed up clinically with routine surveillance endoscopic ultrasound or MRI surveillance every 12 months for a duration of 10 years|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| identifying pancreatic neoplastic lesions lesions in patients with BRCA1/2 mutations and other less common, but related mutations (ATM, PALB2) as well as mutations identified in the future. | The primary objective of the study is the observational screening of patients with BRCA1/2, ATM, or, PALB2 mutations for pancreatic neoplastic lesions, to assess for both the feasibility of this approach in this high risk population as well as to better establish the incidence of these lesions in this cohort. | 10 years | 

 Terms related to the study
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Keywords Provided by Centre Hospitalier Valida
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high risk, specifically those with BRCA1/2 mutations