Diagnosis, staging and treatment planning

Evidence summary and stakeholder input

The following is a summary of the findings from the evidence gathering activities and stakeholder consultations undertaken to inform development of the Roadmap. For more information on the development of the Roadmap see the About page.

Last updated: 31 March 2022

Diagnosis and staging

Evidence summary

The diagnosis of pancreatic cancer is primarily imaging-based, although there is significant variation in the modality of imaging performed.

The pancreatic cancer optimal care pathway (OCP) suggests that diagnosis should include contrast-enhanced computed tomography (CT) and, if diagnostic uncertainly remains, endoscopic ultrasound (EUS) with or without biopsy, magnetic resonance imaging (MRI) and/or laparoscopy, with or without ultrasound. Staging involves CT of the chest/ abdomen/ and pelvis and positron emission tomography (PET), MRI and laparoscopy, with or without ultrasound. 

The pancreatic cancer OCP specifies the importance of staging in treatment planning and prognosis, with synoptic reporting (the process of reporting specific data elements in a specified format in surgical pathology reports) encouraged where operative resection has occurred, and pathological staging is available. The use of protocols and algorithms for investigation and staging can assist to ensure uniformity and equity of access to high quality care.¹⁻³ Specifically, increased pancreatic protocol-based imaging can play an important role in identifying patients who would most benefit from surgery or neoadjuvant treatment.  

An analysis of the Upper Gastrointestinal Cancer Registry (UGICR) indicated that CT chest/ abdomen/and pelvis was not performed in all patients. Despite the critical role of pancreatic protocol CT (PPCT) for assessing localised disease, only 37% of patients within the UGICR received imaging according to this protocol. Of those CT images taken, 90% were undertaken as per protocol. There were no observable differences in the characteristics of patients who received diagnostic imaging by different imaging modalities. 

Further, EUS was performed in approximately half of cases, and biopsy in 80% of patients who underwent EUS. There were no differences in the demographic characteristics of patients who received EUS or tissue biopsy. 

A higher proportion of patients from regional (28%) or remote (32%) areas received imaging including an MRI scan, when compared with those from major cities (23%).  The difference in for these variations needs to be explored. Consistent with the pancreatic cancer OCP recommendations, a greater proportion of patients with metastatic disease underwent less scanning compared with those with no metastases identified. 

Multidisciplinary care is an integral component of cancer care and can improve patient outcomes.⁴ Multidisciplinary team meetings (MDM) are meetings that involve all relevant health professionals (a multidisciplinary team (MDT)) discussing all appropriate treatment options and making joint recommendations about treatment and supportive care plans, taking into account the personal preferences of patients.⁴ The pancreatic cancer OCP recommends that most diagnostic procedures should be completed prior to the MDM. Around 42% of patients on the UGICR had clinical stage documented at diagnosis. However, there did not appear to be any demographic differences in whether clinical stage was known. Full staging of patients with localised disease also appeared to be lacking and this lack of diagnostic workup/staging limits treatment options for patients. 

Adherence to imaging protocols could be increased through improved education and the introduction of a synoptic reporting template.  In addition, opportunities exist to improve diagnostic accuracy, safety, sample adequacy and quality, needle technical performance and cost of EUS-guided biopsy.⁵ 

Detailed population level data on timeframes from diagnostic investigations to treatment are lacking. Standardising diagnostic tests and staging, and reducing the time from referral to imaging, presentation at the MDM, and definitive treatment would support more patients to receive treatment according to the pancreatic cancer OCP. 

Stakeholder input

Stakeholders identified variable access to key diagnostic tests and lack of Medicare Benefits Schedule (MBS) funding for PET scans for staging. They supported the mapping of diagnostic infrastructure to identify gaps, the use of imaging protocols, standardised reporting for radiology, MBS rebates for key staging procedures, and implementation of strategies to ensure faster access to diagnostic tests and treatment for people in rural areas.

The importance of timely diagnosis in initiating an effective treatment plan for people from CALD backgrounds was also raised, noting that the point of diagnosis was when the requirement for cultural competence and responsiveness in dealing with CALD consumers and their families was most critical. Indigenous stakeholders also identified the need for better communication in the pre-diagnosis and diagnosis phases, and novel and culturally safe ways to describe diagnosis and treatment options were proposed.

Travelling for diagnostic tests, staging and treatment and being away from family and country take a toll on Aboriginal and Torres Strait Islander people. In addition to displacement from family and country, the costs of travel, accommodation, living expenses and diagnostic tests were highlighted. Increasing affordable access to diagnostic investigations and specialist consultation, and opportunities for initial work-up and some subsequent treatments to be provided closer to home using telemedicine, were also supported by Indigenous stakeholders.

Treatment planning

The pancreatic cancer OCP recommends that all newly diagnosed patients should be discussed in an MDM before beginning treatment.  Overall, around 59% of patients in the UGICR were reviewed by an MDM prior to treatment. Less than half (41%) of patients in the UGICR with metastatic disease were presented to an MDM compared with 84% of those with non-metastatic disease.  In addition, higher proportions of patients aged less than 85 years were referred to an MDM, with only 23% of patients aged 85 years or older presented to an MDM.

A number of barriers to presentation at MDMs have been identified, including lack of awareness of the benefits and/or disagreement that pancreatic cancer patients should be presented at an MDM, and burden of attendance, particularly for radiologists.3 Strengthening referral pathways to MDMs and education about the benefits of presentation at an MDM, support for radiologists by providing streamlined reporting procedures including through teleradiology, and increasing the capacity of MDMs to allow discussion of larger volumes of patients, would increase the proportion of patients reviewed at an MDM.

A Queensland sample of Aboriginal and Torres Strait Islander people diagnosed with pancreatic cancer showed that only 28% were referred to an MDT for treatment planning between 2001 and 2020. Aboriginal and Torres Strait Islander people seen by an MDT tended to be younger, and those diagnosed were more likely to be referred to an MDT following the publication of the pancreatic cancer OCP in 2015, (44% in 2015-2020 compared with 11% before release of the pancreatic cancer OCP). Access to MDTs improved across all remoteness categories following the introduction of the pancreatic cancer OCP.

Stakeholder input

Stakeholders raised the need for increased, rapid and timely access to expert MDTs for treatment planning and to centres of excellence for treatment. In addition, the need for the composition of the MDT to include radiation oncologists, palliative care specialists and experts in culturally appropriate care for Aboriginal and Torres Strait Islander people was highlighted. Stakeholders also raised consideration of separate palliative care MDTs for patients with metastatic pancreatic cancer.

Stakeholders supported developing and publishing current referral pathways to ensure referral of all people diagnosed with pancreatic cancer to an MDT with expertise in the management of pancreatic cancer. The need to capture the proportion and characteristics of patients presented at an MDM was also raised.

Key priority areas, strategies and activities 

Each key priority area has supporting strategies and associated activities for implementation in the short, medium or long term that have been identified to achieve the priority.