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Imaging Tests for the Diagnosis and Staging of Pancreatic Adenocarcinoma
Comparative Effectiveness Review, No. 141
Investigators: Jonathan Treadwell, Ph.D., Matthew Mitchell, Ph.D., Kelley Eatmon, M.P.H., Jane Jue, M.D., M.Sc., Hanna Zafar, M.D., M.H.S., Ursina Teitelbaum, M.D., and Karen Schoelles, M.D., S.M., FACP.
Author Information and AffiliationsStructured Abstract
Objectives:
Our objectives were to synthesize the available information on the diagnostic accuracy and clinical utility of commonly used imaging tests for the diagnosis and staging of pancreatic adenocarcinoma, as well as screening for pancreatic adenocarcinoma in high risk individuals.
Data sources:
We searched Embase, MEDLINE, PubMed, and The Cochrane Library from 1980 through November 1, 2013, for English-language, full-length articles on the role of multidetector computed tomography (MDCT), endoscopic ultrasound with fine-needle aspiration (EUS-FNA), magnetic resonance imaging (MRI), and positron emission tomography–computed tomography (PET/CT) in screening, diagnosis, and staging pancreatic adenocarcinoma. The searches identified 9,776 citations; after screening against the inclusion criteria, we included 15 systematic reviews and 108 primary studies.
Methods:
We extracted data from the included studies and constructed evidence tables. Comparative outcomes of interest included diagnostic accuracy (sensitivity and specificity), staging accuracy, screening accuracy, clinical management, quality of life, survival, and harms of imaging tests. For studies of a single imaging test, the key outcomes were accuracy and procedural harms. Where possible, we pooled the data using bivariate binomial regression models for comparative accuracy. For each pair of tests and each assessed aspect (e.g., determination of metastases), we determined whether the evidence was sufficient to permit a conclusion of a difference, a conclusion of similar accuracy, or neither (i.e., insufficient). We rated the risk of bias of individual studies using an internal validity instrument and graded the overall strength of evidence of conclusions using Evidence-based Practice Center methods. For data on single-test accuracy, procedural harms, patient tolerance, and screening accuracy, we tabulated the important information and summarized the evidence qualitatively.
Results:
We included 15 systematic reviews and 108 primary studies. Regarding comparative accuracy, the evidence was sufficient to conclude that MDCT and EUS-FNA have similar accuracy in assessing resectability in patients whose disease is unstaged, and that EUS-FNA has a slight advantage over MDCT with respect to T (tumor) staging (specifically, a lower chance of undersizing the tumor). Further, we concluded that MDCT and MRI are similarly accurate with respect to both diagnosing and assessing vessel involvement. For PET/CT, evidence was generally inconclusive, but we found low-strength evidence to conclude that PET/CT is more accurate than MDCT in assessing distant metastases (slight advantages in both sensitivity and specificity). None of the included studies reported comparative data on clinical management, survival, quality, or the impact on comparative accuracy of patient characteristics, tumor characteristics, or operator experience. Many studies have reported procedural harms, but harms are generally rare and are different for different imaging modalities. In the screening of people at high risk of developing pancreatic adenocarcinoma, available studies do not correlate the results of a given imaging test to subsequent diagnoses.
Conclusions:
Current evidence permits some tentative conclusions about the comparative assessment of imaging tests for diagnosing and staging pancreatic adenocarcinoma, but many gaps remain. The conclusions we did draw are as follows: MDCT and EUS-FNA have similar accuracy in assessing resectability in patients whose disease is unstaged; EUS-FNA has a slight advantage over MDCT with respect to T (tumor) staging (specifically, a lower chance of undersizing the tumor); MDCT and MRI are similarly accurate with respect to both diagnosing and assessing vessel involvement; and PET/CT is more accurate than MDCT in assessing distant metastases (slight advantages in both sensitivity and specificity). The prominent gaps include minimal information on MDCT angiography, imprecise data on other imaging techniques, a lack of comparative data on patient-oriented outcomes and factors that could influence comparative accuracy, and test-specific data on screening accuracy.
Contents
- Preface
- Acknowledgments
- Key Informants
- Technical Expert Panel
- Peer Reviewers
- Executive Summary
- Introduction
- Methods
- Results
- Introduction
- Results of Literature Searches
- Test Performance of Imaging Modalities for Diagnosis
- Comparative Test Performance of Imaging Modalities for Diagnosis
- Test Performance of Imaging Modalities for Staging
- Comparative Test Performance of Imaging Modalities for Staging
- Harms of Imaging Modalities
- Test Performance of Imaging Modalities for Screening Asymptomatic Adults at High-Risk
- Discussion
- References
- Abbreviations and Acronyms
- Glossary of Selected Terms
- Appendixes
Suggested citation:
Treadwell JR, Mitchell MD, Eatmon K, Jue J, Zafar H, Teitelbaum U, Schoelles K. Imaging Tests for the Diagnosis and Staging of Pancreatic Adenocarcinoma. Comparative Effectiveness Review No. 141. (Prepared by the ECRI Institute-Penn Medicine Evidence-based Practice Center under Contract No. 290-2012-00011-I.) AHRQ Publication No.14-EHC045-EF. Rockville, MD: Agency for Healthcare Research and Quality. September 2014. www.effectivehealthcare.ahrq.gov/reports/final.cfm.
This report is based on research conducted by the ECRI Institute-Penn Medicine Evidence-based Practice Center (EPC) under contract to the Agency for Healthcare Research and Quality (AHRQ), Rockville, MD (Contract No. 290-2012-00011-I). The findings and conclusions in this document are those of the authors, who are responsible for its contents; the findings and conclusions do not necessarily represent the views of AHRQ. Therefore, no statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
The information in this report is intended to help health care decisionmakers—patients and clinicians, health system leaders, and policymakers, among others–make well informed decisions and thereby improve the quality of health care services. This report is not intended to be a substitute for the application of clinical judgment. Anyone who makes decisions concerning the provision of clinical care should consider this report in the same way as any medical reference and in conjunction with all other pertinent information, i.e., in the context of available resources and circumstances presented by individual patients.
This report may be used, in whole or in part, as the basis for development of clinical practice guidelines and other quality enhancement tools, or as a basis for reimbursement and coverage policies. AHRQ or U.S. Department of Health and Human Services endorsement of such derivative products may not be stated or implied.
This report may periodically be assessed for the urgency to update. If an assessment is done, the resulting surveillance report describing the methodology and findings will be found on the Effective Health Care Program Web site at: www.effectivehealthcare.ahrq.gov. Search on the title of the report.
This document is in the public domain and may be used and reprinted without special permission. Citation of the source is appreciated.
Persons using assistive technology may not be able to fully access information in this report. For assistance contact vog.shh.qrha@eraChtlaeHevitceffE.
None of the investigators have any affiliations or financial involvement that conflicts with the material presented in this report.
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