Discontinuing Surveillance of Low-Risk Branch-Duct Intraductal Papillary Mucinous Neoplasms in Routine Practice: An External Application of the "Trivial" Criteria and the Resources it Would Release in Fourteen Health Systems.

Abstract

Background: Surveillance of low-risk branch-duct intraductal papillary mucinous neoplasms is usually lifelong. Criteria to stop it after 5 years of stability in older patients have not been tested outside the center that devised them, nor has their economic value been measured.

Objective: To test these criteria in an independent cohort and measure the lesions missed and the resources released.

Methods: Single-center cohort of patients with a low-risk lesion at diagnosis was followed for at least 12 months with cross-sectional imaging at baseline and during surveillance. The outcome was any new worrisome feature or high-risk stigma. Risk after stability was estimated by conditional analysis. Released resources were valued at the marginal cost beyond the fifth year and priced with fourteen tariffs. Sensitivity analyses addressed discounting, horizon, adherence and basket composition.

Results: Among 392 patients followed for 2375 person-years, 66 (16.8%) developed a new feature; three had high-grade dysplasia or carcinoma, and none died of the neoplasm. The 5-year risk of a new feature did not fall with stability (14.3% after 2 years, 12.5% after five), but no resection and no high-grade lesion occurred after 4 years. Discontinuation would have discharged 101 patients (25.8%), releasing 298 person-years and 79,316 euro per 1000 patients entering surveillance, with no high-grade lesion missed. Across health systems, the same rule released 42,000 to 170,000 euros.

Conclusion: Discontinuation missed no high-grade lesion, although the upper bound of that rate remained 0.84 per 100 person-years. The resources released varied more than fourfold between health systems and must be recomputed locally.