Pancreatic cancer screening: is there a test, and who may be offered one

Is there a screening test?

• Adults without symptoms: the USPSTF recommends against screening for pancreatic cancer (grade D, reaffirmed 2019), by any method. It applies to adults not known to be at high risk. (USPSTF, 2019)
• Why: pancreatic cancer is uncommon in the general population, the accuracy of the possible tests is uncertain, and the outlook is poor even when it is treated early. The USPSTF found no evidence that screening improves deaths from pancreatic cancer and judged the harms, from false positives and from treatment, to be at least moderate. (USPSTF, 2019)
• Other groups: the American Cancer Society says no major professional group recommends routine screening for people at average risk. (ACS) The AGA says clinicians should not screen people at average risk. (AGA, 2020)
• Why it is hard to find early: the pancreas is deep inside the body, so early tumors cannot be seen or felt during a routine exam, and people usually have no symptoms until the cancer is large or has spread. (ACS)

Other risk factors, such as new-onset or long-standing diabetes, older age, smoking, obesity or chronic pancreatitis, raise risk to a lesser degree. The USPSTF counts people with these as part of the general population, so the grade D covers them. (USPSTF, 2019) The other screenings with a D grade are on screening tests you may not need, and every cancer screening the USPSTF does recommend is on cancer screenings by age.

Who may be offered surveillance instead

The USPSTF advice does not cover people at high risk because of an inherited syndrome, such as Peutz-Jeghers syndrome or hereditary pancreatitis, or because of familial pancreatic cancer. (USPSTF, 2019) For them, expert groups describe regular imaging, called surveillance. The CAPS consortium, an international group of experts, set out who is eligible and when to start. (CAPS, 2020)

• How often: once a year if nothing concerning is found; sooner, at 3 or 6 months, if a finding needs a closer look. (CAPS, 2020) The AGA also gives 12 months when there are no concerning findings. (AGA, 2020)
• When it stops: CAPS reached no agreement on an age to stop. (CAPS, 2020) The AGA says to consider stopping when a person is more likely to die of another cause. (AGA, 2020)
• Where: CAPS says surveillance should be done in a research setting by teams in centers with the right expertise, (CAPS, 2020) and the AGA advises a registry or a pancreas center of excellence when possible. (AGA, 2020) NCI notes that people at increased risk may be able to get screening through a clinical trial. (NCI)
• Genetic counseling: the AGA says to consider genetic testing and counseling for relatives in families with pancreatic cancer who may be eligible. (AGA, 2020) The American Cancer Society strongly recommends talking with a genetic counselor, nurse or doctor before any genetic test. (ACS)

For scale: the average lifetime risk of pancreatic cancer in the US is about 1 in 64, and with two first-degree relatives who had it, about 8%. (CAPS, 2020) What a BRCA result means: BRCA test results. Which screenings start earlier with a family history: family history and screening. How to gather it: how to collect your family health history.

What the tests are like

The USPSTF found no evidence on how accurate CT, MRI or endoscopic ultrasound are for finding pancreatic cancer in the general population. (USPSTF, 2019) At the first visit, CAPS also advises a fasting blood sugar or A1c test, repeated during follow-up. (CAPS, 2020) What those numbers mean: A1c and blood sugar results.

The possible harms, from NCI:

• False positives: a result that looks abnormal when there is no cancer, which can lead to worry and to more invasive tests with their own risks;
• Overdiagnosis: some findings would never cause a problem in a person's lifetime;
• False negatives: a normal result when cancer is present, which can delay diagnosis. (NCI)

In two studies of people at high risk, most reported normal levels of distress or worry during screening. (USPSTF, 2019) Both CAPS and the AGA say the limits and risks should be discussed before surveillance starts. (CAPS, 2020)(AGA, 2020) More: false positives and overdiagnosis.

Cysts on the pancreas are sometimes found by chance on a scan done for another reason. Most do not carry a raised risk of cancer; they are usually watched with repeat scans. (NCI)

Why CA 19-9 is not a screening test

CA 19-9 is a tumor marker measured in a blood sample. (MedlinePlus)

• It is not specific: high levels can come from cancers of the pancreas, bile duct, colon and rectum, stomach, ovaries or bladder, and also from gallstones, bile duct infection or blockage, pancreatitis, cirrhosis, other liver disease and cystic fibrosis. (MedlinePlus)
• It can miss cancer: some people do not make CA 19-9 even when they have a cancer that usually produces high levels. (MedlinePlus)
• How it is used: mainly to follow a known cancer and its treatment, and to check whether cancer has come back. Providers do not use it alone to screen for or diagnose cancer. (MedlinePlus) In surveillance, CAPS uses it only when imaging shows a concerning finding. (CAPS, 2020)

The USPSTF says there are currently no accurate, validated blood markers for finding pancreatic cancer early. (USPSTF, 2019) On blood tests sold to look for many cancers at once: multi-cancer early detection blood tests.

New-onset diabetes after 50: a research question

Pancreatic cancer can cause diabetes because the tumor destroys the cells that make insulin. More often it causes small changes in blood sugar that show up only on blood tests. (ACS, symptoms) Most people who develop diabetes later in life will never develop pancreatic cancer. (NCI, symptoms)

• Studies cited by CAPS show that 0.4% to 0.8% of people aged 50 or older with new-onset diabetes are diagnosed with pancreatic cancer within 3 years. Models that use weight loss, age and the trend in blood sugar to pick out who may need a closer look are being studied. (CAPS, 2020)
• No group recommends checking everyone with new diabetes for pancreatic cancer. The USPSTF counts new-onset diabetes as a lesser risk factor covered by its grade D. (USPSTF, 2019)
• For people already in surveillance, CAPS and the AGA say new-onset diabetes should prompt further tests. (CAPS, 2020)(AGA, 2020)

Which screenings apply once you have diabetes: screenings if you have diabetes.

Where they differ:

• Whether people at high risk should be screened: NCI says people at increased risk should be screened. (NCI) CAPS recommends surveillance for selected people at high risk but in a research setting, and says its benefits, risks and costs still need more study. (CAPS, 2020) The AGA says it should be considered. (AGA, 2020) The USPSTF did not rate screening for this group. (USPSTF, 2019)
• One affected relative: NCI describes increased risk with two or more close family members who had pancreatic cancer, and says screening may still be advised even when a genetic test finds no gene change. (NCI) CAPS says advice for people with one affected relative is the same as for people with no family history, unless they carry one of the listed gene changes. (CAPS, 2020)
• Which test: CAPS and the AGA prefer MRI/MRCP and endoscopic ultrasound, (CAPS, 2020)(AGA, 2020) while NCI says CT is the most commonly used screening test. (NCI)
• Age to start: for families without a known gene change, CAPS says 50 or 55 and the AGA says 50, or in both cases 10 years younger than the youngest affected relative. For Peutz-Jeghers syndrome, CAPS says 40 and the AGA says 35. (CAPS, 2020)(AGA, 2020)
• Hereditary pancreatitis: the AGA lists it among the syndromes to consider screening for; CAPS experts did not agree on whether or how to do surveillance for it. (AGA, 2020)(CAPS, 2020)

Symptoms to report

Pancreatic cancer usually has no early signs, and symptoms often begin after it has spread. (NCI, symptoms) The symptoms below are more often caused by other, less serious conditions, but they need checking:

• yellow skin or whites of the eyes (jaundice), often with itchy skin, dark urine and pale stools;
• pain in the upper or middle belly and the back;
• weight loss without trying and loss of appetite;
• tiredness, nausea and vomiting, bloating or indigestion;
• changes in your stools, such as diarrhea or constipation. (NCI, symptoms)(NHS)

The NHS says to ask for an urgent appointment if your skin or the whites of your eyes turn yellow, if you have been vomiting for more than 2 days or have had diarrhea for more than 7 days, and to see a doctor if you have lost a noticeable amount of weight or other symptoms have not improved after 2 weeks. (NHS) A new blood clot, especially with other symptoms, should also lead to more tests. (NCI, symptoms) Because these are symptoms, the USPSTF grade D does not apply. (USPSTF, 2019) The tests a doctor may then arrange: NHS, pancreatic cancer tests and next steps.

Your doctor decides what your result means for you.

This page does not give surgery, medicine or treatment advice. If you have a flagged result, see after an abnormal screening result for questions to ask.

Questions people ask

Is there a screening test for pancreatic cancer?

Not for adults without symptoms who are not known to be at high risk. The USPSTF recommends against screening them by any method (grade D, reaffirmed 2019). The American Cancer Society says no major professional group recommends routine screening for people at average risk, because no screening test has been shown to lower the risk of dying from it. (USPSTF, 2019) (ACS)

Can a CA 19-9 blood test screen for pancreatic cancer?

No. Gallstones, pancreatitis, liver disease and other conditions can also raise it, and some people do not make CA 19-9 even when they have a cancer that usually produces it. Providers do not use it alone to screen for or diagnose cancer. The USPSTF says there are currently no accurate, validated blood markers for finding pancreatic cancer early. (MedlinePlus) (USPSTF, 2019)

My parent had pancreatic cancer. Should I be screened?

Ask your doctor or a genetic counselor. Expert groups advise surveillance only for people with certain inherited gene changes or several affected relatives, and with one affected relative the CAPS group says the advice is the same as for people with no family history. Your doctor can tell you whether genetic counseling fits your family history. (CAPS, 2020) (AGA, 2020)

Is new diabetes after 50 a sign of pancreatic cancer?

Rarely. Most people who develop diabetes never develop pancreatic cancer. The CAPS group cites studies showing that 0.4% to 0.8% of people aged 50 or older with new-onset diabetes are diagnosed with pancreatic cancer within 3 years, and checking people with new diabetes for it is still being studied. NCI says to talk with your doctor about other signs if you have new diabetes and no known risk factors for it. (CAPS, 2020) (NCI, symptoms)

Which symptoms should I report?

Yellow skin or eyes (jaundice), pain in the upper or middle belly and the back, weight loss without trying, loss of appetite, and changes in your stools. They are more often caused by something else, but they need checking. (NCI, symptoms) (NHS)

Related

• BRCA test results: positive, negative and VUS
• Family history: when screening starts earlier
• Cancer screenings by age
• Screening tests you may not need
• Multi-cancer early detection blood tests
• Ovarian cancer screening: CA-125 and ultrasound