Table 2

Statements that reached consensus

Statement	Agreement grade	grade
At what age should pancreatic surveillance begin?
1. For patients with a familial risk (no known germline mutations or PJS), screening should begin by the age of… 45 years or 10 years younger than the youngest relative with PDAC 50 years or 10 years younger than the youngest relative with PDAC 55 years or 10 years younger than the youngest relative with PDAC	10.3% 67.6% 22.1%	4 2 2
2. For germline mutation carriers (excluding PJS), screening should begin 5 years earlier than for high-risk individuals with defined familial pancreatic cancer	74.7%	2
3. For patients with PJS, screening should begin at least by the age of… 30 years or 10 years younger than the youngest relative with PDAC 35 years or 10 years younger than the youngest relative with PDAC 40 years or 10 years younger than the youngest relative with PDAC	14.9% 17.9% 67.2%	4 4 2
4. New-onset diabetes in a high-risk individual should lead to initiation of screening, regardless of age.	82.4%	2
How should high-risk individuals be screened?
5. Baseline pancreatic screening tests should include (multiple answers allowed) EUS MRI/MRCP CT Abdominal ultrasound	86.8% 92.1% 19.7% 2.6%	2 2 4 5
6. Follow-up pancreatic screening tests should include (multiple answers allowed) EUS MRI/MRCP CT Abdominal ultrasound	89.5% 89.5% 15.8% 1.3%	2 2 4 5
7. CA19-9 should be used as an additional surveillance test for individuals with worrisome features on imaging	76.5%	2
8. Routine testing for diabetes mellitus with fasting blood glucose and/or haemoglobin A1c should be performed.	76.1%	2
Surveillance questions
9. In the absence of pancreatic abnormalities, the recommended surveillance interval is 12 months	90.4%	2
10. For patients with small (<1 cm), non-functioning neuroendocrine tumours, the recommended surveillance interval is 12 months	82.6%	2
11. For patients with low-risk findings (ie, pancreatic lobulation or a cyst without worrisome features), the recommended surveillance interval is 12 months	88.6%	2
12. For CDKN2A p16 mutation carriers with newly detected pancreatic abnormalities that are concerning but do not lead to surgery (mild MPD dilation, stricture without mass), repeat imaging should be performed within 3–6 months	98.5%	2
13. A diagnosis of new-onset diabetes* in an HRI under surveillance, prompts immediate investigations	90.3%	2
14. Smoking status does not affect the surveillance interval	76.8%	2
15. When a cystic lesion with worrisome features (ie, mural nodule, solid component, duct dilation, etc) is detected, EUS-FNA should be performed.	84.3%	2
16.When a solid lesion is detected, CT should be performed	95.7%	1
17. At detection of a solid lesion, EUS-FNA should be performed… Always If ≥5 mm If ≥10 mm Never	70.1% 19.4% 4.5% 6.0%	2 1 1 5
18. When a solid lesion of uncertain significance is newly detected and the patient is not referred for surgery, imaging should be repeated after 3 months	91.2%	1
19. Standardised nomenclature should be used to define chronic pancreatitis-like abnormalities	98.6%	2
20. When an asymptomatic MPD stricture with an associated suspicious mass is detected… EUS-FNA should be performed Surgery should be performed	75.7% 81.2%	1 2
21. When an asymptomatic MPD stricture of unknown aetiology (without a mass) is detected… CT should be performed EUS-FNA should be performed	86.6% 77.9%	1 1
22. When a patient with an MPD stricture is not referred for surgery, repeat imaging should be performed within 3 months	98.5%	1
When should surgery be performed?
23. A solid lesion, detected by EUS (except biopsy-proven or highly suspicious to be neuroendocrine, autoimmune or other benign conditions) should be resected… Regardless of size When ≥5 mm When ≥10 mm	64.7% 77.9% 91.2%	4 1 1
24. In an HRI undergoing pancreatic screening, an IPMN should be resected in case of… A mural nodule An enhanced solid component Symptoms, including pancreatitis, jaundice, pain Thickened/enhanced cyst walls Abrupt change in MPD with distal pancreatic atrophy An MPD ≥10 mm	91.0% 97.0% 95.5% 76.1% 91.0% 97.0%	1 1 1 1 1 1
25. Pancreatic resections should be performed at specialty centres	95.9%	1
26. In cases of suspected PC, an oncological radical resection is indicated	92.9%	1
27. When an HRI undergoes surgery for suspected small PC (max. 1 cm, T1M0N0 on imaging), a partial pancreatectomy is suitable	89.6%	2
Goals of surveillance
28. Detection and treatment of the following pathological lesion should be considered a 'success' of a screening programme: Resected cancer, confined to the pancreas, with negative margins, at baseline Resected cancer, confined to the pancreas, with negative margins, at follow-up Multifocal PanIN-3 Unifocal PanIN-3 IPMN with high-grade dysplasia Pancreatic neuroendocrine tumour ≥10 mm	96% 85% 99% 97% 97% 75%	1 1 2 2 1 2

CA19-9, carbohydrate antigen 19–9; CDKN2A, cyclin-dependent kinase inhibitor 2A; CT, computed tomography; EUS, endoscopic ultrasound; FNA, fine-needle aspiration; HRI, high-risk individual; IPMN, intraductal papillary mucinous neoplasm; MPD, main pancreatic duct; MRI/MRCP, magnetic resonance imaging/magnetic retrograde cholangiopancreatography; PanIN-3, pancreatic intraepithelial neoplasia-3; PC, pancreatic ductal adenocarcinoma; PDAC, pancreatic ductal adenocarcinoma; PJS, Peutz-Jeghers syndrome.