Diagnosis and staging

Most diagnostic procedures should be completed before the MDM. Biopsy is only required where there is diagnostic uncertainty, or tissue is required for further management or clinical trials.

A contrast-enhanced CT scan should be completed first if not already performed. Additional tests may also be requested by the multidisciplinary team. If diagnostic uncertainty still remains, conduct:

• endoscopic ultrasound with or without biopsy
• contrast-enhanced MRI of the pancreas or magnetic resonance cholangiopancreatography (MRCP) in patients who cannot tolerate contrast or where diagnostic uncertainty remains
• diagnostic laparoscopy with or without laparoscopic ultrasound when resection is planned.

Staging pancreatic cancer may include the following investigations:

• CT scan of the chest/abdomen/pelvis and PET scan
• MRI pancreatic and/or liver
• laparoscopy plus or minus laparoscopic ultrasound for high-risk patients.

Genetic testing

Five to 10 per cent of pancreatic cancers arise due to a genetic predisposition.

A referral to a familial cancer service should be considered for all patients newly diagnosed with pancreatic cancer, particularly if any of the following features are noted:

• a family history of pancreatic cancer
• young age of diagnosis (< 60 years)
• a personal and/or family history of melanoma, breast, ovarian, stomach or colorectal cancer
• a family history of chronic pancreatitis
• Ashkenazi Jewish ancestry.

Treatment planning

The patient’s case must be discussed within 1 week of completing the diagnostic and staging investigations and a management plan should be finalised.

Research and clinical trials

Consider enrolment where available and appropriate. Search for a trial.

Communication

The lead clinician’s (1) responsibilities include:

• discussing a timeframe for diagnosis and treatment options with the patient and/or carer
• explaining the role of the multidisciplinary team in treatment planning and ongoing care
• encouraging discussion about the diagnosis, prognosis, advance care planning and palliative care while clarifying the patient’s wishes, needs, beliefs and expectations, and their ability to comprehend the communication
• providing appropriate information and referral to support services as required
• communicating with the patient’s GP about the diagnosis, treatment plan and recommendations from multidisciplinary meetings (MDMs).

Checklist

Timeframe

Diagnostic and staging investigations should be completed within 2 weeks of referral.