November 21, 2023
Chang JH, Wehrle C, Hossain MS, et al. A Practical Strategy to Reduce Surgical Overtreatment of Intraductal Papillary Mucinous Neoplasms of the Pancreas. Ann Surg. 2023, in press.
Intraductal papillary mucinous neoplasms (IPMN) are common cystic lesions of the pancreas, with as many as 6 million Americans having this type of pancreatic cyst. Because certain types of IPMN are precursors of pancreatic cancer (PDAC) surgeons are frequently challenged with balancing the benefit of cancer prevention with the risk of surgical morbidities associated with pancreatic resection.
Identification of high-risk IPMN is accomplished using surveillance imaging (CT and/or MRI), cyst fluid cytology, serum biomarkers, and cyst fluid testing for DNA, RNA, and protein molecular alterations in multiple testing panels. Recommended surveillance strategies are described in the Fukuoka Consensus promulgated by the International Association of Pancreatology.
The authors noted that current surveillance strategies do not categorize patients according to age. Available evidence shows that risk for progression from benign to high-risk IPMN increases with advancing age. Risks for operative mortality and morbidity also increase with increasing age. They used Markov modelling to determine age-related risk using large datasets of healthy individuals and patients with IPMN.
The data analysis showed that improved survival after prophylactic resection is present up to age 60, while resection of IPMN identified as high-risk provided improved survival up to age 75. The authors recommended that surgical resection should not be performed in patients over 80 years of age with high-risk IPMN. Prophylactic resection was not recommended for patients >60 years of age.
Authors cautioned that estimation of age-related benefit should not be viewed as a single means of determining whether to recommend surgical resection; it can be used along with other information when counselling patients regarding a decision for use of prophylactic resection or resection of high-risk lesions.
Barnell EK, Wurtzler EM, La Rocca J. Multitarget Stool RNA Test for Colorectal Cancer Screening. JAMA. 2023;330(18):1760-1768.
This article described data from a phase 3 prospective clinical trial that was designed to determine the potential for improved detection of colorectal cancer and/or advanced adenomas after adding analysis of eight RNA transcripts to a commercially available fecal immunochemical test.
A total of 8,920 patients underwent the multi-target RNA stool test (mt-sRNA) followed by colonoscopy. Patients were older than 45 years and resided in 49 states; colonoscopies were performed in 3,800 different endoscopy centers. The outcomes of interest were the sensitivity of the mt-sRNA test for identifying colon cancer or advanced adenomas and the specificity for predicting no lesions discovered on colonoscopy.
The data showed that 0.4% of study participants were diagnosed with colon cancer and 6.8% had advanced adenomas. The sensitivity of the mt-sRNA test for detecting cancer was 94% and specificity for identifying patients with no lesions was 88%; sensitivity for adenoma detection was 46%. Of note, the sensitivity of the FIT test alone was 78% for cancer detection and 29% for adenoma detection.
The authors concluded that the mt-sRNA test significantly improved the accuracy of non-invasive fecal testing for diagnosis of colorectal cancer and advanced adenomas.
Sodhi M, Rezaeianzadeh R, Kezouh A, Etminan M. Risk of Gastrointestinal Adverse Events Associated with Glucagon-Like Peptide-1 Receptor Agonists for Weight Loss. JAMA. 2023;330(18):1795-1797.
Glucagon-like peptide (GLP-1) agonists are medications currently approved for treatment of diabetes. They are frequently used off-label as weight loss medications. Diabetic patients are at increased risk for gastrointestinal adverse events such as biliary disease, pancreatitis, bowel obstruction, and gastroparesis, but clinical trials were not designed to quantify these risks in patients taking GLP-1 agonists.
Using national databases, the authors determined the frequency of gastrointestinal adverse events in patients taking GLP-1 agonists for weight loss (n = 5,157) compared with patients taking bupropion-naltrexone.
The data analysis showed that risk for pancreatitis, bowel obstruction, and gastroparesis were significantly increased in patients taking GLP-1 agonists; risk for biliary disease was not increased. The increased risk persisted after adjustment for the presence of obesity.
The authors concluded that patients should be counselled regarding the risk for gastrointestinal adverse events prior to beginning treatment with GLP-1 agonists for weight loss.