RWJBarnabas Health Pioneers Innovative Pancreatic Cyst Surveillance Program

Russell Langan, MD

The incidental identification of pancreatic cysts has become more common with the increasing use of imaging modalities in clinical practice. Currently, an estimated 15% of Americans are believed to harbor a pancreatic cyst.¹ Unlike other cysts within the body, pancreatic cysts are unique in that many pose an increased risk for development of pancreas cancer over a patient’s lifetime. Although certain cysts can be benign, when mucinous, such as intraductal papillary mucinous neoplasms or mucinous cystic neoplasms, these cysts are a marker of increased pancreatic cancer risk—even when small and without high-risk features.^2,3 In fact, for certain pancreatic cysts, like main duct intraductal papillary mucinous neoplasm, the risk of pancreatic cancer can be as high as 70%.⁴ Therefore, those with pancreatic cysts require lifelong surveillance and certain patients also need surgical intervention to decrease their risk of developing pancreas cancer.

Pancreatic cancer accounts for 3% of all new cancer diagnoses, but is the fourth leading cause of cancer death in the United States.⁵ Therefore, it is imperative that we, as a community, focus our efforts on learning more about precancerous conditions within the pancreas and the early identification of cancers; pancreatic cysts are an ideal target. There are 2 key components to remember with regard to pancreatic cysts: accurate identification and evidence-based longitudinal surveillance. Unfortunately, an ongoing issue for this patient population is that many are never appropriately identified or followed. However, even when identified, many patients are not referred to a pancreatic center of excellence, a gastroenterologist who focuses on the pancreas, or a surgeon with experience in pancreatic cysts. As a result, these patients can re-present years later with a pancreatic cancer.

Our institution, Saint Barnabas Medical Center, an RWJBarnabas Health Facility, in conjunction with the Rutgers Cancer Institute of New Jersey, has made efforts to focus on preventative care. Specifically, we have recently focused our attention on pancreatic cysts and partnered

with Eon to develop and implement a platform called Essential Patient Management (EPM) Pancreas to identify patients with a pancreatic abnormality, and then, longitudinally follow them using an innovative and modern cloud-based platform that includes automatic patient and physician reminders.

Through the adoption of Eon EPM Pancreas, patients who now undergo either ultrasound, computed tomography, or magnetic resonance imaging in our Emergency Department, inpatient setting, or outpatient imaging facility, will be automatically identified if they are found to have an abnormality within their pancreas. The patient will then be contacted by one of our preventative medicine nurse navigators with a phone call and a letter; they will also be offered consultation with our pancreatic care team. Additionally, the patient’s ordering physician will also be contacted with a letter and a call. This algorithm links all parties together and lets them know about the pancreatic abnormality that may harbor precancerous potential. This automatic identification and population of cyst factors into the cloud-based platform accomplishes the first key component to remember with these cysts.

The second component is accomplished through individual risk stratification. The pancreatic cyst size, tempo of growth, pancreatic duct caliber, mural nodularity, evidence of pancreatitis, tumor markers, pancreatic cyst fluid aspirate for carcinoembryonic and amylase levels, and, at times, genetic mutations are added to the Eon EPM dashboard. Putting these factors together, along with national and international guidelines, we determine how to best manage and follow a particular patient. Previously, this has been done by using an Excel spreadsheet. However, now, with the EPM platform, we can advance healthcare and manage patients electronically; the cloud-based system embeds into our institution’s electronic medical record (EMR) system, and with that, all the aforementioned factors can be seen immediately at the time of consultation. Moreover, we have extrapolated the method of a “tumor board” into our pancreatic cyst clinic and we now have a weekly pancreatic multidisciplinary conference where we discuss our patients with pancreatic cysts, thus providing them with a multidisciplinary/team approach.

Eon EPM offers the most powerful Pancreas solution that uses best-in-class technology to identify incidental pancreatic abnormalities, and longitudinally track patients who require serial surveillance. Eon EPM uses sophisticated proprietary models, referred to as Computational Linguistics data science models, to positively identify incidentally found pancreatic abnormalities with 93.9% accuracy; this high accuracy rate means fewer missed patients and less coordinator effort. Moreover, EPM can integrate with any facility’s EMR and IT system, and through Robotic Process Automation, it automates many mundane and repetitive tasks.

Eon EPM Pancreas detects incidental pancreatic abnormalities noted in radiology reports, extracts pertinent information from these reports such as pancreatic cyst characteristics, enters all information into one dashboard for serial surveillance, ensures patients are tracked and followed according to evidence-based guidelines, segments and prioritizes patients based on risk stratification, and triggers follow-up.

In summary, there are 2 overarching goals of this program. The first is to improve the quality in identifying patients with pancreatic cysts and longitudinally following them to ensure that they do not fall through the cracks within the community in which they are being served. The second goal is to offer patients surgery only when it is indicated because the great majority of pancreatic cysts only require lifetime surveillance—not an operation. If we can identify high-risk pancreatic cysts and surgically remove them prior to the development of pancreas cancer and prevent other patients from having an unnecessary operation, we believe that to be a massive improvement in how patients are being cared for. I have no doubt that Eon EPM Pancreas Solution will change the landscape for patients with pancreatic cysts and tumors, and have a true impact on survival from pancreatic-related diseases.

References

1. Vege SS, Ziring B, Jain R, et al, American gastroenterological association institute guideline on the diagnosis and management of asymptomatic neoplastic pancreatic cysts. Gastroenterology. 2015;148(4): p. 819-822; quize12-3. doi:10.1053/j.gastro.2015.01.015
2. European Study Group on Cystic Tumours of the Pancreas. European evidence-based guidelines on pancreatic cystic neoplasms. Gut. 2018;67(5):789-804. doi:10.1136/gutjnl-2018-316027
3. Elta GH, Enestvedt BK, Sauer BG, et al. ACG Clinical Guideline: Diagnosis and Management of Pancreatic Cysts. Am J Gastroenterol. 2018;113(4):464-479. doi:10.1038/ajg.2018.14
4. Hackert T, Fritz S, Klauss M, et al. Main-duct Intraductal Papillary Mucinous Neoplasm: High Cancer Risk in Duct Diameter of 5 to 9 mm. Ann Surg. 2015;262(5):875-880. doi:10.1097/SLA.0000000000001462
5. Siegel RL, Miller D, Jemal A. Cancer statistics, 2020. CA Cancer J Clin. 2020;70(1):7-30. doi:10.3322/caac.21590

Russell Langan, M.D., is chief of Surgical Oncology and Hepatopancreatobiliary Surgery at Saint Barnabas Medical Center (SBMC), an RWJBarnabas Health facility, and surgical oncologist at Rutgers Cancer Institute of New Jersey.