Pancreatic Cancer

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  • Casey, Good discussion points. The problem of inter-rater reliability is common in medical research of this type where investigators are required to gather and assess information. Sometimes a study will have a third rater, or even a panel of experts, to make a final determination if the two raters don't agree. Some questions: What type of study would you call your project? without going back to review this again, did you say that the risk categories (high, medium and low) were determined by the article you cited as a 'gold standard' ? and did you consider (or are you aware) of other statistical measures to use for a study like this, such as positive predictive value, negative predictive value (of the doctors' or GC's assessments), or an ROC curve? There's a lot to learn in statistics---and sometimes people learn just enough to get them into trouble---but you did a pretty good job. Doctors (and probably genetic counselors too) don't look critically enough at their own profession to see where they're not performing well or how they could improve. A study like the one you did here can provide good feedback to healthcare practitioners. Sometimes it's left up to the health consumer--patients and their families---to choose specialists wisely based on this kind of research. Thank you!
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Pancreatic Cancer

  1. 1. Casey Lipton
  2. 2.  Pancreatic Ductal Adenocarcinoma one of the least treatable forms of Cancer Only 8% of people diagnosed diagnosed in early stages when surgical removal of tumor is possible One-year survival rate for patients with stages three and four Pancreatic Adenocarcinoma 26% and five-year survival rate 6% Five-year survival rate for patients with stage one or stage two Pancreatic Adenocarcinoma 23%
  3. 3.  Male, African American patients, Jewish patients, patients between 60 and 80, patients with diabetes and patients who smoke Ten percent of cases due to hereditary conditions ◦ Peutz-Jegher’s Syndrome, Hereditary Nonpolyposis Colorectal Cancer, BRCA 1/2 mutations, Familial Atypical Multiple Mole Melanoma Syndrome, Familial Pancreatitis
  4. 4.  No standard screening protocol, but tests that pick up precancerous legions (i.e. EUS, MRI, CT scans) Health History questionnaires, Doctor’s Charts and Genetic Counselors used to obtain demographic information and family history of cancer
  5. 5.  Evaluate health history questionnaires, genetic counselor pedigrees and doctors’ charts to develop a system to classify patients into risk groups for early diagnosis Focuses on higher and lower risk patients as opposed to just higher risk patients
  6. 6.  Genetic counselor provides more accurate demographic information and personal and familial histories of cancer Health history questionnaire provides more detailed on demographic information Some patients thought to be in lower or higher risk groups should be placed in different risk groups based on questionnaires, doctor’s charts and genetic counselor risk assessments
  7. 7.  Patients from Columbia Presbyterian Hospital Prevention group (considered higher risk) taken from Pancreas Center Prevention and Genetics Program Surgical Patients visited Columbia Presbyterian for surgery for Pancreatic Cancer Patients excluded from either group if they did not have health history questionnaire, doctor’s chart or genetic counselor pedigree (Prevention Patients)
  8. 8.  Completed by all patients with demographic information, personal and first, second and third degree relatives histories of cancer
  9. 9.  Completed by prevention patients with mainly personal and family histories of cancer
  10. 10.  Filled out by physicians or medical assistants for all patients with basic demographic information
  11. 11.  Average Risk: 1 family member with pancreatic cancer who >55 years old or no family members with pancreatic cancer Moderate Risk: 2+ first, second, or third degree relatives with pancreatic cancer or 1 first-degree relative with pancreatic cancer <55 years old High Risk: 3+ first, second, or third degree relatives with pancreatic cancer, 2+ first-degree relatives with pancreatic cancer or 1 first and one second degree relative with pancreatic cancer <55 years old Based on Pancreatic Cancer Screening in a Prospective Cohort of High-Risk Patients: A Comprehensive Strategy of Imaging and Genetics
  12. 12.  Surgical Patients: compared demographic information from HHQ and Chart Prevention Patients: compared demographic information from HHQ, chart and genetic counselor pedigree Prevention Patients: compared personal and family histories of cancer from HHQ and genetic counselor pedigree using kappa statistical test Risk category of each patient determined based on HHQ and genetic counselor pedigree Amount and clarity of information analyzed to find most effective way to classify patients
  13. 13.  61 Pancreas Prevention Patients had HHQ, Genetic Counselor and Chart data available, 33 female patients 252 Surgical Patients had HHQ and Chart data available, 112 female
  14. 14.  Kappa values between 0.4672 and 1.000 for personal history of cancer in Prevention Program group Kappa values between 0.7005 and 1.000 for first degree relatives histories of cancer in Prevention Program group Kappa values between 0.312 and 0.8924 for second degree relatives histories of cancer in Prevention Program group Kappa values between -0.0526 and 0.7248 for third degree relatives histories of cancer in Prevention Program group
  15. 15.  22 high-risk patients, 19 moderate-risk patients, 20 average-risk patients in Prevention Program as recorded by GC 18 high-risk patients, 18 moderate-risk patients, 25 average-risk patients in Prevention Program as recorded by HHQ 3 high-risk patients, 15 moderate-risk patients, 234 average-risk patients in Surgical group as recorded by HHQ
  16. 16.  HHQ, GC and Chart reported similar data for age, race, religion, smoking, diabetes, HHQ asked most specific demographic questions, so little demographic information missing from Prevention and Surgical Patients Demographic information left out of genetic counselor pedigrees and doctor’s charts because they record less biographical information
  17. 17.  Higher level of agreement (higher kappa values) for personal history of cancer and first degree relatives’ histories of cancer Lower level of agreement (lower kappa values) for second degree relatives’ histories of cancer and third degree relatives’ histories of cancer Many more second and third degree relatives reported by GC
  18. 18.  18 surgical patients who should have been placed in moderate or high-risk groups based on family histories Genetic counselor provides more detailed information on family histories Sending all patients to genetic counselor neither time nor cost efficient HHQ with more specific family history questions as an intermediary step before genetic counselor meetings
  19. 19.  1. Admehin Jamel (2011, 10 28). American cancer society. Retrieved from http://www.cancer.org/acs/groups/content/@epidemiologysurveilance/documents/document/acspc-029771.pdf 2. Palliative care: Easing the course of serious illness - MayoClinic.com. (n.d.). Mayo Clinic. Retrieved July 1, 2012, from http://www.mayoclinic.com/health/palliative-care/MY01051 3. Risk Factors For Pancreas Cancer. (n.d.). Johns Hopkins Pathology. Retrieved August 12, 2012, from http://pathology.jhu.edu/pc/BasicRisk.php?area=ba 4. Klein AP, Hruban RH, Brune KA, Petersen GM, Goggins M. Familial pancreatic cancer. Cancer J 2001;7:266-73. 5. Screening for Pancreatic Cancer. (n.d.). U.S. Preventive Services Task Force. Retrieved August 12, 2012, from http://www.uspreventiveservicestaskforce.org/uspstf/uspspanc.htm 6. Verna EC, Hwang C, Stevens PD, et al. Pancreatic cancer screening in a prospective cohort of high-risk patients: a comprehensive strategy of imaging and genetics. Clinical Cancer Res. 2010;16(20):5028-37.5 7. Canto MI, Hruban RH, Fishman EK, et al. Frequent detection of pancreatic lesions in asymptomatic high-risk individuals. Gastroenterology. 2012;142(4):796-804. 8. Chalmers, K. I., Luker, K. A., Leinster, S. J., Ellis, I., & Booth, K. (2001). Information and support needs of women with primary relatives with breast cancer: development of the information and support needs questionnaire. Journal of Advanced Nursing, 35(4), 497-507. Doi:10.1046/j.1365-2648.2001.01866.x. 9. Ziogas, A., & Anton-Culver, H. (2003). Validation of family history data in cancer family registries. American Journal of Preventive Medicine, 24(2), 190-198. Doi:10.1016/S0749-3797(02) 005930- 7. 10. Vasen HF, Möslein G, Alonso A, et al. Recommendations to improve identification of hereditary and familial colorectal cancer in Europe. Fam Cancer. 2010;9(2):109-15. 11. Schofield L, Goldblatt J, Iacopetta B. Challenges in the diagnosis and management of Lynch Syndrome in an Indigenous family living in a remote West Australian community. Rural Remote Health. 2011;11(4):1836. 12. Hallowell, N., Murton, F., Statham, H., Green, J. M., & Richards, M. P. (1997). Women’s need for information before attending genetic counseling for familial breast or ovarian cancer: a questionnaire, interview, and observational study. BMJ (Clinical Research Ed), 281, 7076-283. 13. Armel, S. R., McCuaig, J., Finch, A., Densky, R., Panzarella, T., Murphy, J., et al. (2009). The effectiveness of family history questionnaire in cancer genetic counseling. Journal of Genetic Counseling, 18(4), 366-378. 14. Armel SR, Hitchman K, Millar K, et al. The use of family history questionnaires: an examination of genetic risk estimates and genetic testing eligibility in the non-responder population. J Genet Couns. 2011;20(4):355-64. 15. Armel SR, Mccuaig J, Finch A, et al. The effectiveness of family history questionnaires in cancer genetic counseling. J Genet Couns. 2009;18(4):366-78. 16. Ferrante JM, Ohman-strickland P, Hahn KA, et al. Self-report versus medical records for assessing cancer-preventive services delivery. Cancer Epidemiol Biomarkers Prev. 2008;17(11):2987-94. 17. Fleiss JL, Cohen J, Everitt BS. Large sample standard errors of kappa and weighted kappa. Psychol. Bull. 1969;72:323

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