Progress, challenges, and future directions of pancreatic cancer surveillance in high-risk populations

Pancreatic cancer remains one of the most lethal malignancies because most patients are diagnosed with advanced disease, when curative treatment is rarely possible. Population-wide screening is not currently recommended because pancreatic cancer remains relatively uncommon. Early detection efforts therefore focus on surveillance of individuals at substantially elevated risk, including those with hereditary cancer syndromes, pathogenic germline variants, or a strong family history of pancreatic cancer. Surveillance is primarily performed using magnetic resonance imaging and endoscopic ultrasound to detect early-stage cancer or high-risk precursor lesions. In this Review, we summarise current evidence for pancreatic cancer surveillance in high-risk populations. We discuss approaches to risk identification, surveillance eligibility, imaging strategies, and reported clinical outcomes. We also examine important challenges, including interval cancers, risk stratification, psychological impact, cost-effectiveness, and implementation in clinical practice. Finally, we review emerging approaches, including biomarkers and risk prediction models, that may further improve early detection. Poh et al. review current evidence on pancreatic cancer surveillance in individuals with hereditary cancer syndromes and familial pancreatic cancer. Surveillance is associated with earlier-stage diagnosis, higher resection rates, and improved survival, although challenges remain in risk stratification, implementation, and early cancer detection.