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Initial Misdiagnosis of Proximal Pancreatic Adenocarcinoma Is Associated With Delays in Diagnosis and Advanced Stage At Presentation
Douglas S. Swords*, Mary C. Mone, Sean J. Mulvihill, Courtney L. Scaife
Division of General Surgery, The University of Utah, Salt Lake City, UT
BACKGROUND:Delay in diagnosis is associated with a worse prognosis in numerous cancers. However, the impact of a delay in diagnosis for pancreatic adenocarcinoma is not well defined. We hypothesized that a significant number of patients with proximal pancreatic adenocarcinoma are initially misdiagnosed. We sought to determine whether initial misdiagnosis was associated with delay in definitive diagnosis and whether misdiagnosis was associated with stage at the time of diagnosis.
METHODS: The cancer registry at a tertiary referral cancer center from 2001 to 2009 was retrospectively reviewed for new cases of proximal (uncinate, head, and neck) pancreatic adenocarcinoma. Patients initially treated at another center were excluded. Date of symptom onset, date of correct diagnosis, AJCC stage at time of diagnosis, initial misdiagnoses and procedures occurring as a result of initial misdiagnoses were recorded. Statistical analyses included Mann-Whitney and Chi-Square testing.
RESULTS: A total of 269 patients met study criteria. Of those, 91 patients (33.8%) received one or more misdiagnoses prior to confirming pancreatic adenocarcinoma. The most common misdiagnoses were gallbladder problems, pancreatitis, and GERD (Table 1). After excluding patients with remote history of cholecystectomy from analysis (n=35), 33 of 234 patients (14.1%) were incorrectly diagnosed with a gallbladder etiology and underwent cholecystectomy after cancer symptom onset but before correct diagnosis. The median time from symptom onset to correct diagnosis was 120 days in those initially misdiagnosed (range 2-1,234) versus 44 days in patients that received an initial diagnosis of cancer (range 5-499)(p<0.001). There was no difference in patient gender; with 59.3% male in misdiagnosed group versus 51.7% (p=0.23). Patients were younger in the misdiagnosed group with a median age of 63 years (range 32-91), versus 69 (range 45-87), (p=0.001). A trend was noted in the AJCC stage at diagnosis between groups (p=0.07) (Table 2). When comparing patients with stage IV disease at time of diagnosis to a combined group of stages I through III, 34.1% of misdiagnosed patients were stage IV versus 21.9% of those not misdiagnosed (p=0.03). The risk was 84% higher for misdiagnosed patients to be stage IV at diagnosis when compared to those who were not (OR 1.84, 95% CI 1.05, 3.23).
CONCLUSIONS: At this single center, one third of cases of proximal pancreatic cancer had an initial misdiagnosis. Initial misdiagnosis was associated with increased amount of time from symptom onset to diagnosis and with metastatic disease at the time of diagnosis. The symptoms associated with pancreatic cancer can be subtle and are often attributed to more common upper abdominal diagnoses. Physicians should have a low threshold to pursue dedicated studies in search of a pancreatic cancer in the right clinical context.
Table 2. Misdiagnosed and correctly diagnosed patients divided by stage at time of diagnosis
| % (n) | Number of Days from Symptoms to Cancer Diagnosis | | | Median | 25th, 75th percentile | Minimum | Maximum | | Stage I | | | | | | | Initial Misdiagnosis | 6.6 (6) | 124 | 38,171 | 35 | 910 | | Initial Correct Diagnosis | 5.6 (10) | 57 | 39, 71 | 12 | 137 | | Stage II | | | | | | | Initial Misdiagnosis | 36.3 (33) | 134 | 68, 193 | 40 | 558 | | Initial Correct Diagnosis | 52.2 (93) | 45 | 27, 80 | 5 | 419 | | Stage III | | | | | | | Initial Misdiagnosis | 23.1 (21) | 120 | 76, 301 | 21 | 1088 | | Initial Correct Diagnosis | 20.2 (36) | 52 | 33, 86 | 10 | 236 | | Stage IV | | | | | | | Initial Misdiagnosis | 34.1 (31) | 120 | 94, 280 | 2 | 1234 | | Initial Correct Diagnosis | 21.9 (39) | 33 | 22, 53 | 6 | 499 |
Table 1. Etiologies of misdiagnosis in 91 patients | Etiology | N | | Gallbladder | 34 | | Pancreatitis | 19 | | Gastroesophageal reflux disease | 15 | | Peptic ulcer disease/gastritis/esophagitis | 12 | | Common bile duct stricture | 6 | | Medication reaction | 5 | | Unexplained abdominal/back pain treated with pain medications | 5 | | Diverticulitis | 4 | | Cardiac | 3 | | Functional gastrointestinal disorder | 3 | | Liver | 3 | | Pancreatic pseudocyst | 3 | | Other | 5 |
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