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Genetic Test: Germline Genetic Testing for Pancreatic Cancer Susceptibility Genes | |
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Description: |
Pancreatic cancer is the fourth leading cause of cancer death in the U.S., accounting for 7.9% of all cancer deaths in 2021 (NIH, 2019). The disease has a poor prognosis, with only 10.8% of patients surviving to 5 years. Five-year survival for localized pancreatic cancer is 41.6% but most symptomatic patients have advanced, incurable disease at diagnosis.
Approximately 10%-15% of patients with pancreatic cancer are thought to have a hereditary susceptibility to the disease (Stoffel, 2019). Multiple genetic syndromes, including hereditary breast and ovarian cancer syndrome, are associated with an increased risk for pancreatic cancer. Five percent to 9% of pancreatic ductal adenocarcinomas (PDACs) develop in patients with a germline BRCA or PALB2 variant, with higher rates observed in those with a family or personal history of pancreatic cancer or other BRCA-related malignancies (O’Reilly, 2020). The incidence of germline PALB2 mutations in persons with PDAC is estimated to be between 0.6% and 2.1% (Reiss, 2018).
Having a first-degree relative with pancreatic cancer increases an individual's risk of developing pancreatic cancer, and the degree of risk increases depending on the number of affected relatives (Owens, 2019). Individuals are considered at high-risk for hereditary pancreatic cancer if they have 2 relatives with pancreatic cancer where 1 is a first-degree relative, have 3 or more relatives with pancreatic cancer or have a history of hereditary pancreatitis. In 80% of pancreatic cancer patients with a family history of pancreatic cancer, the genetic basis of the inherited predisposition is unknown (NCCN, 2021).
Germline genetic testing for pancreatic cancer susceptibility genes has several proposed purposes. In patients with pancreatic cancer, the purpose of genetic testing would be to guide treatment decisions (e.g., selection of platinum-based chemotherapy for first-line treatment, targeted treatment with a poly ADP ribose polymerase [PARP] inhibitor). In asymptomatic patients at high risk of pancreatic cancer (e.g., due to family history or other clinical factors), the purpose of genetic testing would be to inform decisions about surveillance for early detection of pancreatic cancer. Because the incidence of pancreatic cancer in the general population is low, with a lifetime risk of approximately 1.6%, screening is not recommended for patients who are not at high-risk, but patients with a family history of pancreatic cancer or a syndrome associated with increased risk of pancreatic cancer are potential targets for surveillance.
Regulatory Status
Testing for variants associated with pancreatic cancer is typically done by direct sequence analysis or next-generation sequencing. Several laboratories offer to test for the relevant genes, either individually or as panels.
Clinical laboratories may develop and validate tests in-house and market them as a laboratory service; laboratory-developed tests must meet the general regulatory standards of the Clinical Laboratory Improvement Amendments (CLIA). Lab Test X is available under the auspices of the CLIA. Laboratories that offer laboratory-developed tests must be licensed by the CLIA for high-complexity testing. To date, the U.S. Food and Drug Administration (FDA) has chosen not to require any regulatory review of this test.
In December 2019, the FDA approved olaparib (LYNPARZA, AstraZeneca Pharmaceuticals LP) for the maintenance treatment of adult patients with deleterious or suspected deleterious germline BRCA-mutated metastatic pancreatic adenocarcinoma, as detected by an FDA-approved test, whose disease has not progressed on at least 16 weeks of a first-line platinum-based chemotherapy regimen. Also in 2019, BRACAnalysis CDx received expanded FDA approval for use as a companion diagnostic for Lynparza (olaparib) in pancreatic cancer patients (FDA, 2019)
Coding
There is no test specifically for pancreatic cancer. For purposes of this policy, the following codes may be billed.
CPT codes for PALB2 testing:
CPT codes for BRCA1 & BRCA2 testing:
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Policy/ Coverage: |
Effective July 15, 2022
Meets Primary Coverage Criteria Or Is Covered For Contracts Without Primary Coverage Criteria
Genetic testing for BRCA1, BRCA2, and PALB variants to guide selection for treatment with platinum-based chemotherapy in previously untreated patients with locally advanced or metastatic pancreatic cancer meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
Genetic testing for BRCA1 and BRCA2 variants to guide selection for treatment with olaparib (Lynparza) in patients with pancreatic cancer meets member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
Does Not Meet Primary Coverage Criteria Or Is Investigational For Contracts Without Primary Coverage Criteria
Genetic testing for BRCA1, BRCA2, and PALB variants to guide selection for treatment of pancreatic cancer not described above does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
For members with contracts without primary coverage criteria, genetic testing for BRCA1, BRCA2, and PALB variants to guide selection for treatment of pancreatic cancer not described above is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
Genetic testing for ATM, CDK2NA, EPCAM, MMR genes (MLH1, MSH2, MSH6, PMS2), STK11, and TP53 in patients with pancreatic cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
For members with contracts without primary coverage criteria, genetic testing for ATM, CDK2NA, EPCAM, MMR genes (MLH1, MSH2, MSH6, PMS2), STK11, and TP53 in patients with pancreatic cancer is considered investigational.
Genetic testing for ATM, BRCA1, BRCA2, CDK2NA, EPCAM, MMR genes (MLH1, MSH2, MSH6, PMS2), STK11, and TP53 in asymptomatic individuals at high risk for hereditary pancreatic cancer does not meet member benefit certificate primary coverage criteria that there be scientific evidence of effectiveness in improving health outcomes.
For members with contracts without primary coverage criteria, genetic testing for ATM, BRCA1, BRCA2, CDK2NA, EPCAM, MMR genes (MLH1, MSH2, MSH6, PMS2), STK11, and TP53 in asymptomatic individuals at high risk for hereditary pancreatic cancer is considered investigational. Investigational services are specific contract exclusions in most member benefit certificates of coverage.
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Rationale: |
Genetic Testing for a BRCA1, BRCA2, or PALB2 Variant to Select First-Line Treatment
There is no direct evidence from RCTs of the clinical utility of germline testing for BRCA or PALB2 variants in patients with pancreatic cancer. Several retrospective observational studies and an uncontrolled subgroup analysis from a randomized controlled trial of veliparib have reported a survival advantage for pancreatic cancer patients with BRCA or PALB2 pathogenic variants who received platinum-containing chemotherapy.
Golan et al analyzed survival data and clinical characteristics from databases of pancreatic cancer patients treated at 3 institutions between 1994 and 2012, including 71 patients with BRCA1 or BRCA2 variants (Golan, 2014). Longer median overall survival was observed in patients with BRCA variants who received platinum-based chemotherapy compared to those who received non-platinum-based chemotherapies (22 months [range 6–27] vs 9 months [range 4–12]; P =.039).
Three retrospective cohort studies used similar methods to compare survival outcomes in patients with or without BRCA or PALB2 variants who were treated with platinum-based chemotherapy (Wattenberg, 2020; Yu, 2019; Reiss, 2018). In these studies, patients with a pathogenic variant were matched to control patients on prognostic factors such as age at diagnosis, sex, and stage of disease. All of these studies reported a survival advantage when variant-positive patients were treated with platinum vs non-platinum-based regimens, while there was no advantage for platinum-based therapy in patients who did not harbor a BRCA or PALB2 variant.
Major limitations include the studies’ small sample sizes and retrospective designs. The timing of genetic testing varied within the patient cohorts (e.g. some patients were tested before and others after their pancreatic cancer diagnosis). It is possible that patients who survived their PDAC diagnosis longer were more likely to undergo genetic testing. Because many control patients were not tested, some may have been variant-positive. However, this is less of a concern because this would have biased results toward the null. There was also heterogeneity in the timing and type of chemotherapy regimens patients received. Although the studies attempted to control for confounding by matching patients on important prognostic factors or using statistical analysis methods, the potential for unmeasured confounding decreases confidence in the results. Despite these limitations, consistency in the magnitude and direction of results across studies suggest that a strategy of testing for these variants to aid in decision-making about first-line treatment is a reasonable approach.
O’Reilly et al conducted an RCT of platinum-based chemotherapy with or without the PARP inhibitor veliparib in patients with previously untreated, locally advanced or metastatic pancreatic cancer and a BRCA or PALB2 germline variant (O’Reilly,2020). Two-year OS rate for the entire cohort was 30.6%(95%CI, 17.8%to 44.4%), and 3-year OS rate for the entire cohort was 17.8% (95% CI, 8.1% to 30.7%).Overall survival did not differ significantly when veliparib was added to the platinum-based regimen. The trial was not designed to compare platinum-based vs standard chemotherapy, but it does provide uncontrolled evidence of the effectiveness of platinum-containing chemotherapy in patients with germline pathogenic BRCA or PALB2 variants. The major limitation of this analysis was the lack of a control group of patients who did not receive platinum-based chemotherapy.
Genetic Testing for a BRCA1 or BRCA2 Variant to Select Targeted Treatment
Golan et al. conducted a placebo controlled RCT of olaparib as maintenance therapy in patients with germline BRCA1 or BRCA2 variants and metastatic pancreatic cancer (Golan, 2019). Of 3315 patients screened, 247 (7.5%) had a germline BRCA mutation. Median progression-free survival was longer in the olaparib group, but there was no difference in OS.
Genetic Testing for ATM, CDK2NA, EPCAM, MLH1, MSH2, MSH6, PMS2, STK11, and TP53 to Guide Treatment in Individuals with Pancreatic Cancer
Multiple observational studies have demonstrated that testing patients with pancreatic cancer can identify individuals with disease-associated variants; A case-control analysis conducted by Hu et al compared the association of germline pathogenic variations in 3030 patients with pancreatic cancer to 176241 controls from 2 public genome databases (Hu, 2018). There were significant associations between pancreatic cancer and pathogenic variations in 6 genes associated with pancreatic cancer (ATM, BRCA1, BRCA2, CDKN2A, MLH1, and TP53). Overall, pathogenic variants were identified in 5.5% of patients with pancreatic cancer.
Observational studies have reported that pathogenic variants are found in patients with pancreatic cancer who do not have a family history of the disease. In Hu et al pancreatic cancer associated variants were found in 7.9% of patients with a family history of pancreatic cancer and 5.2% of those without a family history of pancreatic cancer (Hu, 2018). Shindo et al reported that pathogenic variants were identified in 3.9% of a cohort of 854 patients with pancreatic adenocarcinoma (Shindo, 2017). Of those with an identified pathogenic variant, only 3 (9.0%) reported a family history of pancreatic cancer.
There are currently no targeted treatments for pancreatic cancer based on germline testing for ATM, CDK2NA, EPCAM, MLH1, MSH2, MSH6, PMS2, STK11, or TP53. It is unclear what management changes would be implemented based on results of such testing.
Genetic Testing in Asymptomatic Individuals who are at Risk for Hereditary Pancreatic Cancer
Multiple genetic syndromes, including hereditary breast and ovarian cancer syndrome, are associated with an increased risk for pancreatic cancer. Most of these are also associated with increased risk of other cancers. However, individual genes associated with the syndromes have been identified as increasing risk of pancreatic cancer, even in the absence of one of these syndromes.
A prospective observational study of individuals under surveillance for pancreatic cancer based on a family history of pancreatic cancer identified a known pathogenic variant in a pancreatic cancer susceptibility gene in 4.3% (15/345) (Abe, 2019). In addition, 66 variants of unclear significance were identified. The cumulative incidence of pancreatic cancer in the germline mutation group was higher than in the familial risk group, adjusted for age and sex and accounting for death as a competing event (HR, 2.85; 95% CI, 1.0 to 8.18; P =.05).
Surveillance in Asymptomatic Individuals at High Risk for Hereditary Pancreatic Cancer
Recent prospective observational studies have reported the yield of screening and outcomes in high-risk individuals enrolled in pancreatic cancer surveillance programs. Surveillance protocols varied somewhat and evolved over time, but typically included annual MRI and/or endoscopic ultrasound, with more frequent follow-up when a suspicious lesion was identified.
A 16-year follow-up study of surveillance in individuals at high-risk of pancreatic cancer due to family history or genetic factors was reported by Canto et al (Canto, 2018). The overall detection rate over 16 years was 7%, including incident and prevalent neoplasms. Of 354 individuals under surveillance, 10 pancreatic cancers were detected, and 9 of 10 were resectable. Among these, 85% survived for 3 years.
Vasen et al found that surveillance of CDNK2A mutation carriers detected most pancreatic adenocarcinomas at a resectable stage (Vasen, 2016). In patients at risk for familial pancreatic cancer (those from families with 2 or 3 first-degree relatives with pancreatic cancer), however, the yield of screening was low.
Konings et al published a report of outcomes on 76 high-risk individuals from CAPS surveillance programs in 4 countries (U.S., the Netherlands, Israel, and Italy) who had either undergone pancreatic surgery because of the detection of a suspicious pancreatic lesion (n=71) or progressed to advanced unresectable malignant disease (n=5) (Konings, 2019). Survival rate was significantly poorer for individuals with advanced pancreatic cancer compared with those who had surgery (40% vs. 83% respectively, P =0.050; mean survival 9.5 vs. 54.3 months, P <0.001).
Although observational studies have demonstrated that surveillance can identify pancreatic cancer and precursor lesions in asymptomatic individuals, it is not possible to conclude from this body of evidence that surveillance improves survival. Longer survival time observed in individuals undergoing surveillance could simply be due to earlier identification of the disease (lead-time bias) and not the effects of early intervention and treatment.
Practice Guidelines and Position Statements
American College of Gastroenterology
In 2015, the American College of Gastroenterology Clinical Guideline on Genetic Testing and Management of Hereditary Gastrointestinal Cancer Syndromes includes the following recommendations on genetic testing for pancreatic cancer (Syngal, 2015):
American Society of Clinical Oncology
In 2019, an American Society of Clinical Oncology (ASCO) opinion statement addressed the identification and management of patients and family members with a possible predisposition to pancreatic adenocarcinoma and made the following recommendations (Stoffel, 2019):
In 2020, ASCO published a guideline update on recommendations for second-line therapy options for metastatic pancreatic cancer (Sohal, 2020). In patients who have a germline BRCA1 or BRCA2 mutation and who have received first-line platinum-based chemotherapy without disease progression for at least 16 weeks, options for continued treatment include chemotherapy or the PARP inhibitor olaparib.
International Cancer of the Pancreas Screening Consortium
In 2020, the International Cancer of the Pancreas Screening Consortium published an updated consensus document on the management of patients with increased risk for familial pancreatic cancer (Goggins, 2020). The panel recommended pancreatic cancer surveillance performed in a research setting for the following individuals:
The preferred surveillance tests are endoscopic ultrasound and magnetic resonance imaging (MRI). The recommended age to initiate surveillance depends on an individual's gene mutation status and family history, but no earlier than age 50 or 10 years earlier than the youngest relative with pancreatic cancer. There was no consensus on the age to end surveillance.
National Comprehensive Cancer Network
Two National Comprehensive Cancer Network (NCCN) guidelines address germline genetic testing in individuals with or at high risk for pancreatic cancer (NCCN, 2021).
The Guidelines on Genetic/Familial High-risk Assessment: Breast, Ovarian, and Pancreatic (v.2.2021) recommend germline testing for all individuals with exocrine pancreatic cancer, and specify that testing of first-degree relatives should only be done only if it is impossible to test the individual who has pancreatic cancer (NCCN, 2021).
The Guideline on Treatment of Pancreatic Adenocarcinoma (v.1.2021) recommends germline testing for any patient with confirmed pancreatic cancer using comprehensive gene panels for hereditary cancer syndromes (NCCN, 2021). The guideline specifies the following genes as those typically tested for pancreatic cancer risk: ATM, BRCA1, BRCA2, CDKN2A, most Lynch syndrome genes (MLH1, MSH2, MSH6, EPCAM), PALB2, STK11, and TP53. For patients with locally advanced disease, preferred first-line therapy regimens include gemcitabine + cisplatin for patients with BRCA1/2 or PALB2 variants For patients with metastatic disease who have received previous platinum-based chemotherapy, olaparib is preferred only for patients with germline BRCA 1/2 variants.
Genetic counseling is recommended for patients who test positive for a pathogenic variant, or for patients with a positive family history of pancreatic cancer, regardless of test results. The guidelines also recommend genetic counseling for patients who test positive for a pathogenic variant or for patients with a positive family history of pancreatic cancer, regardless of variant status.
Ongoing and Unpublished Clinical Trials
Some currently unpublished trials that might influence this review are listed below.
Ongoing
NCT03140670 A Phase 2, Open Label Study of Rucaparib in Patients With Advanced Pancreatic Cancer and a Known Deleterious Germline or Somatic BRCA or PALB2 Mutation (Completion Date: Jun 2022)
NCT02790944a Utilizing a Multi-gene Testing Approach to Identify Hereditary Pancreatic Cancer in Consecutive Cases Unselected for Family History (Completion Date: May 2021)
NCT03060720 Systematic Hereditary Pancreatic Cancer Risk Assessment and Implications for Personalized Therapy (Completion Date: Feb 2022)
NCT00835133 Biospecimen Resource for Familial Pancreas Research, a Data and Tissue Registry (Also Known as a Bio-repository, Bio-bank, Data and Tissue Database, Data and Tissue Bank, Etc.) to Help Advance Research in Familial Pancreas Disease (Completion Date: Sep 2022)
NCT02206360 Observational Study to Analyze the Outcomes of Subjects Who - Based Upon Their Sufficiently Elevated Risk for the Development of Pancreatic Adenocarcinoma- Elect to Undergo Early Detection Testing (Completion Date: Mar 2024)
NCT00526578 Pancreatic Cancer Genetic Epidemiology (PACGENE) Study (Completion Date: Jun 2025)
2023 Update
Annual policy review completed with a literature search using the MEDLINE database through March 2023. No new literature was identified that would prompt a change in the coverage statement. The key identified literature is summarized below.
Dbouk et al published results of the CAPS5 cohort, consisting of 1461 individuals who were determined to be at high risk for PDAC based either on presence of a germline pathogenic variant (48.5%) or family history without a known germline pathogenic variant (51.5%) (Dbouk, 2022). A total of 9 individuals were diagnosed with a screen-detected pancreatic adenocarcinoma. The study authors concluded that their results "support current CAPS surveillance recommendations and argue against the notion of limiting pancreatic surveillance to those high-risk individuals with known pathogenic mutations."
In a cohort of 366 Dutch individuals at high risk of PDAC followed for 63 months (standard deviation, 43.2 months), Overbeek et al reported a 9.3% incidence of PDAC in the subset of individuals with a germline pathogenic variant and no PDAC in those with family history but no pathogenic variant (Overbeek, 2022). Three out of 10 (30%) individuals with PDAC were detected at an early stage. The resectability rate was 60% (6/10) overall and 50% (4/8) for incident cases.
2024 Update
Annual policy review completed with a literature search using the MEDLINE database through February 2024. No new literature was identified that would prompt a change in the coverage statement.
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CPT/HCPCS: | |
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References: |
Abe T, Blackford AL, Tamura K, et al.(2019) Deleterious Germline Mutations Are a Risk Factor for Neoplastic Progression Among High-Risk Individuals Undergoing Pancreatic Surveillance. J Clin Oncol. May 01 2019; 37(13): 1070-1080. PMID 30883245 Brand R, Borazanci E, Speare V, et al.(2018) Prospective study of germline genetic testing in incident cases of pancreatic adenocarcinoma. Cancer. Sep 01 2018; 124(17): 3520-3527. PMID 30067863 Canto MI, Almario JA, Schulick RD, et al.(2018) Risk of Neoplastic Progression in Individuals at High Risk for Pancreatic Cancer Undergoing Long-term Surveillance. Gastroenterology. Sep 2018; 155(3): 740-751.e2. PMID 29803839 Dbouk M, Katona BW, Brand RE, et al.(2022) The Multicenter Cancer of Pancreas Screening Study: Impact on Stage and Survival. J Clin Oncol. Oct 01 2022; 40(28): 3257-3266. PMID 35704792 Food & Drug Administration.(2021) Premarket Approval: BRACAnalysis CDx. 2019. https://www.accessdata.fda.gov/scripts/cdrh/cfdocs/cfpma/pma.cfm?id=P140020S019. Accessed January 18, 2021. Goggins M, Overbeek KA, Brand R, et al.(2020) Management of patients with increased risk for familial pancreatic cancer: updated recommendations from the International Cancer of the Pancreas Screening (CAPS) Consortium. Gut. Jan 2020; 69(1): 7-17. PMID 31672839 Golan T, Hammel P, Reni M, et al.(2019) Maintenance Olaparib for Germline BRCA -Mutated Metastatic Pancreatic Cancer. N Engl J Med. Jul 25 2019; 381(4): 317-327. PMID 31157963 Golan T, Kanji ZS, Epelbaum R, et al.(2014) Overall survival and clinical characteristics of pancreatic cancer in BRCA mutation carriers. Br J Cancer. Sep 09 2014; 111(6): 1132-8. PMID 25072261 Grant RC, Selander I, Connor AA, et al.(2018) Prevalence of germline mutations in cancer predisposition genes in patients with pancreatic cancer. Gastroenterology. Mar 2015; 148(3): 556-64. PMID 25479140 Hu C, Hart SN, Polley EC, et al.(2018) Association Between Inherited Germline Mutations in Cancer Predisposition Genes and Risk of Pancreatic Cancer. JAMA. Jun 19 2018; 319(23): 2401-2409. PMID 29922827 Konings ICAW, Canto MI, Almario JA, et al.(2019) Surveillance for pancreatic cancer in high-risk individuals. BJS Open. Oct 2019; 3(5): 656-665. PMID 31592073 Mandelker D, Zhang L, Kemel Y, et al.(2017) Mutation Detection in Patients With Advanced Cancer by Universal Sequencing of Cancer-Related Genes in Tumor and Normal DNA vs Guideline-Based Germline Testing. JAMA. Sep 05 2017; 318(9): 825-835. PMID 28873162 National Comprehensive Cancer Network (NCCN).(2021) Clinical Practice Guidelines in Oncology: Genetic/Familial High-Risk Assessment: Breast, Ovarian, and Pancreatic. Version 2.2021. https://www.nccn.org/professionals/physician_gls/pdf/genetics_bop.pdf. Accessed January 16, 2021. National Comprehensive Cancer Network (NCCN).(2021) Clinical Practice Guidelines in Oncology: Pancreatic Adenocarcinoma. Version 1.2021. https://www.nccn.org/professionals/physician_gls/pdf/pancreatic.pdf. Accessed January 15, 2021. NIH National Cancer Institute: Surveillance, Epidemiology, and End Results Program.(2021) Cancer Stat Facts: Pancreatic Cancer. 2019. https://seer.cancer.gov/statfacts/html/pancreas.html. Accessed January 15, 2021. O'Reilly EM, Lee JW, Zalupski M, et al.(2020) Randomized, Multicenter, Phase II Trial of Gemcitabine and Cisplatin With or Without Veliparib in Patients With Pancreas Adenocarcinoma and a Germline BRCA/PALB2 Mutation. J Clin Oncol. May 01 2020; 38(13): 1378-1388. PMID 31976786 Overbeek KA, Levink IJM, Koopmann BDM, et al.(2022) Long-term yield of pancreatic cancer surveillance in high-risk individuals. Gut. Jun 2022; 71(6): 1152-1160. PMID 33820756 Owens DK, Davidson KW, Krist AH, et al.(2019) Screening for Pancreatic Cancer: US Preventive Services Task Force Reaffirmation Recommendation Statement. JAMA. Aug 06 2019; 322(5): 438-444. PMID 31386141 Reiss KA, Yu S, Judy R, et al.(2018) Retrospective Survival Analysis of Patients With Advanced Pancreatic Ductal Adenocarcinoma and Germline BRCA or PALB2 Mutations. JCO Precision Oncology. Published online January 19, 2018. DOI: 10.1200/PO.17.00152. Shindo K, Yu J, Suenaga M, et al.(2017) Deleterious Germline Mutations in Patients With Apparently Sporadic Pancreatic Adenocarcinoma. J Clin Oncol. Oct 20 2017; 35(30): 3382-3390. PMID 28767289 Sohal DPS, Kennedy EB, Cinar P, et al.(2020) Metastatic Pancreatic Cancer: ASCO Guideline Update. J Clin Oncol. Aug 05 2020: JCO2001364. PMID 32755482 Stoffel EM, McKernin SE, Khorana AA.(2019) Evaluating Susceptibility to Pancreatic Cancer: ASCO Clinical Practice Provisional Clinical Opinion Summary. J Oncol Pract. Feb 2019; 15(2): 108-111. PMID 30589608 Syngal S, Brand RE, Church JM, et al.(2015) ACG clinical guideline: Genetic testing and management of hereditary gastrointestinal cancer syndromes. Am J Gastroenterol. Feb 2015; 110(2): 223-62; quiz 263. PMID 25645574 Vasen H, Ibrahim I, Ponce CG, et al.(2016) Benefit of Surveillance for Pancreatic Cancer in High-Risk Individuals: Outcome of Long-Term Prospective Follow-Up Studies From Three European Expert Centers. J Clin Oncol. Jun 10 2016; 34(17): 2010-9. PMID 27114589 Wattenberg MM, Asch D, Yu S, et al.(2020) Platinum response characteristics of patients with pancreatic ductal adenocarcinoma and a germline BRCA1, BRCA2 or PALB2 mutation. Br J Cancer. Feb 2020; 122(3): 333-339. PMID 31787751 Yu S, Agarwal P, Mamtani R, et al.(2019) Retrospective survival analysis of patients with resected pancreatic ductal adenocarcinoma and a Germline BRCA or PALB2 mutation. JCO Precision Oncol. Published online March 28, 2019. DOI: 10.1200/PO.18.00271 |
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Group specific policy will supersede this policy when applicable. This policy does not apply to the Wal-Mart Associates Group Health Plan participants or to the Tyson Group Health Plan participants.
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