From the AGA Journals

Pancreatic cancer screening in new-onset diabetes appears cost effective

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Investigating risk stratification strategies

Earlier detection of pancreatic ductal adenocarcinoma (PDAC) is essential to improving the survival for the group of patients diagnosed with PDAC each year. New-onset diabetes in adults 50 years or older is recognized as a risk factor for being diagnosed with PDAC within the following 3 years.

Dr. Mark Gromski

This study by Wang et al. uses previously described clinical prediction models to stratify the risk of PDAC in patients with new-onset diabetes. These models include age, body mass index, weight change, smoking, diabetic medications, and laboratory values (hemoglobin A1c, cholesterol, creatinine, alkaline phosphatase). They ran simulation models to determine the cost-effectiveness of screening for pancreatic cancer at various risk cut-offs. At the $150,000 willingness-to-pay threshold per quality-adjusted life-year, the 1% risk threshold was cost-effective. Stage shifting from a higher-stage cancer to a lower-stage cancer was the driving force behind the cost-effectiveness ratios.

Providers need to have a high index of suspicion when an adult over the age of 50 has had a new diagnosis of diabetes. Abnormalities detected in laboratory data, weight trends, symptoms, a history of underlying smoking or pancreatic disease may appropriately prompt an MRI/MRCP or endoscopic ultrasound. Better and more accessible risk progression calculators for these patients could be used in real time. The current study by Wang et al. will be a helpful tool as well for navigating disputes with payers about the utility of covering screening tests in the subgroup of patients that are higher risk.

Mark A. Gromski, MD, is assistant professor of medicine at Indiana University School of Medicine and a pancreatobiliary specialist and advanced endoscopist at IU Health. He reports having no relevant disclosures.



A risk-tailored early-detection strategy for pancreatic cancer that targets patients with new-onset diabetes could be cost effective, according to a recent study.

Screening for pancreatic ductal adenocarcinoma in asymptomatic adults is not recommended, but patients with new-onset diabetes have a risk that’s eight times higher than expected. Screening these patients could improve diagnosis and survival rates if the cancer can be identified at earlier stages, researchers led by Louise Wang, MD, a gastroenterology fellow at the University of Pennsylvania, Philadelphia, wrote in Clinical Gastroenterology and Hepatology.

“As we continue to improve therapies for early-stage pancreatic cancers, especially among the local/resectable stage, the case for the targeted early-detection strategy will be stronger,” they wrote. “Policy makers should take into consideration these novel findings when formulating [pancreatic ductal adenocarcinoma] screening policy and making coverage determinations.”

The research team compared early detection strategies for pancreatic ductal adenocarcinoma that target new-onset diabetes patients at age 50 years and older with standard of care, defined as no early detection strategy. They looked at various minimal predicted cancer risk thresholds versus current standard of care in a Markov state-transition decision model. The analysis assumed a health care sector perspective and a lifetime horizon, with two willingness-to-pay thresholds ($100,000 and $150,000) per quality-adjusted life-year gained.

The researchers used data from one of their previously published studies, which included 89,881 patients with new-onset diabetes diagnosed at age 50 or older. The cumulative incidence of pancreatic cancer was 0.42% during the 3 years after diagnosis.

In the early detection strategy, all patients 50 years and older who were newly diagnosed with diabetes mellitus were placed into low-risk and high-risk cohorts based on their predicted 3-year risk of pancreatic ductal adenocarcinoma under a range of assumed minimum-risk thresholds – 0.5%, 1%, 2%, 3%, 4%, and 5%; these thresholds were based on a previously established prediction model.

The research team found that the early detection strategy that targeted patients with a minimum predicted 3-year pancreatic ductal adenocarcinoma risk of 1% was cost effective, based on a willingness-to-pay threshold of $150,000 per quality-adjusted life-year. The incremental cost-effectiveness ratio was $116,911 per quality-adjusted life-year.

At a willingness-to-pay threshold of $100,000 per quality-adjusted life-year, the early detection strategy at the 2% risk threshold was cost effective. The incremental cost-effectiveness ratio was $63,045 per quality-adjusted life-year.

The most influential factors included the proportion of pancreatic ductal adenocarcinomas detected at the local stage, costs of treatment for metastatic cancer, utilities of local and regional cancers, and sensitivity of screening.

A probabilistic sensitivity analysis confirmed that, at a willingness-to-pay threshold of $150,000, early detection at the 1% risk threshold was favored at 30.6%, followed by the 0.5% risk threshold at 20.4%, compared with the standard of care at 1.7%. In addition, at a willingness-to-pay threshold of $100,000, early detection at the 1% risk threshold was favored at 27.3%, followed by the 2% risk threshold at 22.8%, as compared with the standard of care at 2%.

The two early detection strategies were cost effective, capturing 26%-45% of the pancreatic ductal adenocarcinoma cases in patients with new-onset diabetes.

The study authors noted several limitations, including the inability to incorporate out-of-pocket costs for patients, as well as focusing the analysis on the health care perspective.

“We acknowledge that, by incorporating the full consequences of decisions for all stakeholders, a societal perspective would have offered a more complete view on which to base public policy,” they wrote.

At the same time, “given the substantial prevalence of [new-onset diabetes] among [pancreatic ductal adenocarcinoma] cases, this strategy could improve the survival of a substantial proportion of sporadic PDAC cases in the general population,” they concluded.

The study authors reported various disclosures, including grants and research support from Takeda Pharmaceuticals USA, Janssen Pharmaceuticals, the National Institutes of Health, the Crohn’s and Colitis Foundation, Lilly Oncology, GSK, and Clovis Oncology.

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