Abstract
Description
There is a demographic explosion of patients over the age of 60 expected in the United States and worldwide in the next 20 years. Pancreatic cystic lesions (PCLs) are frequently, incidentally identified in more than a quarter of patients above the age of 70 and while the vast majority of these lesions are indolent, some may develop into malignancy. Similarly, while the risk of hepatocellular carcinoma (HCC) is well established in patients with cirrhosis, the proportion of the elderly population with cirrhosis is rapidly expanding, especially in the setting of metabolic dysfunction-associated steatohepatitis. While multiple guidelines define these high-risk populations and provide recommendations on how and when to implement surveillance, these same guidelines rarely specify when to stop surveillance particularly in cases of advanced age or infirmity where the patient's attributable mortality to the surveyed condition or fitness to receive invasive treatments is unclear. In this Clinical Practice Update (CPU), we review evidence-based, patient-centered, practical approaches to assess appropriateness for PCL and HCC surveillance in older individuals, weighing the balance of potential benefit vs harms and the impact of comorbidities and life expectancy on shared decision-making.Methods
This expert review was commissioned and approved by the AGA Institute Clinical Practice Updates Committee and the AGA Governing Board to provide timely guidance on a topic of high clinical importance to the AGA membership and underwent internal peer review by the Clinical Practice Updates Committee and external peer review through the standard procedures of Clinical Gastroenterology and Hepatology. These best practice advice statements were drawn from a review of the published literature and from expert opinion. Because systematic reviews were not performed, these best practice advice statements do not carry formal ratings regarding the quality of evidence or strength of the presented considerations Best Practice Advice Statements BEST PRACTICE ADVICE 1: Regardless of age, patients with significant comorbidities (ie, age-adjusted Charlson comorbidity index ≥3-5) with incidental pancreatic cystic lesions (PCLs), particularly low risk PCL, should be counseled against routine PCL surveillance because of the low attributable mortality to pancreatic cancer (PC) and high risks due to intervention in this population. BEST PRACTICE ADVICE 2: Patients >65 years of age with PCLs ≤15 mm in size that are stable for 5 years (no concerning growth rate of 3 mm or more per year or 6 mm or more in 2 years) with no worrisome features or high-risk stigmata (as defined by the International Association of Pancreatology) should be considered for discontinuation of surveillance after detailed shared decision-making with the patient, given the potential increased morbidity with intensive surveillance in this population. BEST PRACTICE ADVICE 3: Patients >75 years of age with PCLs <30 mm, that are stable for 5 years (no concerning growth rate of 3 mm or more per year or 6 mm or more in 2 years) with no worrisome features or high-risk stigmata should have a detailed discussion about the questionable value of ongoing surveillance. Surveillance may be discontinued if they understand the small, population-specific risk of future PC or HGD. BEST PRACTICE ADVICE 4: Development of significant comorbidities, as defined above, which may preclude a surgical resection at any time during the surveillance of PCL, even with prior worrisome features or high-risk stigmata with no evidence of HGD or PC, should lead to discussion about the discontinuation of surveillance. BEST PRACTICE ADVICE 5: Surveillance of PCLs in the remnant pancreas after resection of PCLs, with no evidence of HGD or PC on final pathology can be continued, per the advice in Best Practice Advice statements 2 and 3, inclusive of the surveillance period preceding the resection with a discussion of cessation of surveillance after 5 years of stability. BEST PRACTICE ADVICE 6: In patients with HGD in the resected specimen, surveillance with magnetic resonance imaging with magnetic resonance cholangiopancreatography (MRI/MRCP) is advised (every 6 months for 2 years, then annually), as long as the patients remain surgical candidates for a completion pancreatectomy. In those with PC in the resected specimen, surveillance of the remnant pancreas should be based on current oncologic guidelines and treatment course. In patients with resected HGD or PC, physicians should discuss with their oncology teams the discontinuation of surveillance after 5 years of stability in the remnant pancreas if there is no development of worrisome features or high-risk stigmata. BEST PRACTICE ADVICE 7: Oral antivirals for hepatitis B virus and hepatitis C virus lower hepatocellular carcinoma (HCC) risk, but do not eliminate it. HCC surveillance in older adults with viral hepatitis should be based on fibrosis stage and HCC risk rather than age alone. BEST PRACTICE ADVICE 8: HCC surveillance should be considered for older adults with cirrhosis of any etiology because age increases HCC risk, unless life expectancy is low and is less than 1 to 2 years. BEST PRACTICE ADVICE 9: HCC surveillance should stop if estimated life expectancy is low and is less than 1 to 2 years based on medical comorbidities, impaired functional status, or liver decompensation (eg, Child-Turcotte-Pugh C cirrhosis) where liver transplant is not an option. Shared decision-making with patients can inform HCC surveillance decisions.