S3-Guideline “Exocrine Pancreatic Carcinoma” 20071 ... - DGVS

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454 Leitlinie studies with contradictory results, a positive recommendation cannot be given. Recommendation An increased intake of legumes cannot be recommended to reduce the risk of pancreatic carcinoma. Recommendation grade: C, evidence level 2b, strong consensus Comments A protective effect of legumes on the incidence of pancreatic carcinoma was found in two cohort studies that were done on subpopulations (Adventists) [13, 14]. Since both publications included a very special study population a selection bias cannot be excluded. Thus, a general recommendation cannot be given. A benefit of an increased fruit and vegetable intake to reduce the risk of pancreatic cancer can currently not be proven. Recommendation grade: C, evidence level: 2b, strong consensus Comments Increased fruit and vegetable consumption reduced the pancreatic carcinoma risk in several case control studies [3, 4, 15, 16]. However, in a cohort study, which is considered more relevant, no relationship was observed between fruit and vegetable consumption and pancreatic carcinoma risk [17]. Nonetheless, a recommendation that encourages eating fruits and vegetables is rated as desirable, because regular consumption decreases the risk of cancer in general [18]. Recommendation Consuming vitamin C rich foods may help reduce the risk of pancreatic carcinoma. Recommendation grade: D, evidence level 3, majority approval Comments Two case control studies indicate a protective relationship between the consumption of vitamin C rich foods and pancreatic carcinoma [4, 19]. However, the recommendation grade is restricted by limitations of both studies. Parameters such as age and smoking are not sufficiently taken into account by Lin et al. [19] and the population size is too small. Ji et al. [4] only found a significant association between vitamin C rich food and the risk of pancreatic carcinoma in men. A low-fat diet does not help reduce pancreatic carcinoma risk. Recommendation grade: B, evidence level 2b, consensus Comments An increased consumption of saturated fats was associated with a higher pancreatic carcinoma risk in a cohort study with male smokers [20]. This result is consistent with an ecologic study [21]. However, in other cohort studies there was no relationship [7], and in a study with an Asian population an inverse association was even described [4]. A low-cholesterol diet does not help reduce the risk of pancreatic carcinoma. Recommendation grade: B, evidence level 2b, strong consensus Adler G et al. S3-Guideline “Exocrine Pancreatic… Z Gastroenterol 2008; 46: 449–482 Comments In a case control study an increased pancreatic carcinoma risk was seen in the group with a high cholesterol diet [19]. However, this observation could not be confirmed in a cohort study [8]. The reduction of red meat consumption does not help reduce the risk of pancreatic carcinoma. Recommendation grade: B, evidence level 2b, strong consensus Comments The studies on this topic are contradictory. The consumption of red meat was connected with an increased risk of pancreatic carcinoma in a cohort study [7]. However, it remained unclear whether the red meat itself or the way it was prepared was responsible for the risk association [22]. No relationship between the consumption of red meat and the risk of pancreatic carcinoma was found in two other studies of which one was a cohort study by Michaud et al. [4, 8]. Therefore, it must be assumed that the positive association described by Nothlings [7] is most likely caused by the way the meat was prepared rather than by the consumption of the meat itself. This leads to the overall evaluation that reducing red meat consumption is not associated with a reduced pancreatic carcinoma risk. A relationship between the preferred consumption of white meat and pancreatic carcinoma risk cannot be reported. Recommendation grade: B, evidence level 2b, strong consensus Comments There are two studies that deal with this topic. Both found no association between the consumption of white meat and pancreatic carcinoma risk [7, 22]. The consumption of smoked/grilled food may be associated with an increased risk of pancreatic carcinoma. Recommendation grade: C, evidence level 3, majority approval Comments Three studies show that the consumption of smoked/grilled foods is associated with a higher pancreatic carcinoma risk [22 – 24]. However, all three studies are merely case control studies so that an evidence level of 3 can be given. An increased consumption of fish should not be recommended to decrease the risk of pancreatic carcinoma. Recommendation grade: B, evidence level 2b, consensus Comments Two cohort studies [7, 8] showed no relationship between fish consumption and pancreatic carcinoma risk. Thus, two case control studies that showed a protective effect are less important [5, 25]. A general recommendation to reduce the consumption of sugar cannot be given. Recommendation grade: B, evidence level 2b, consensus Comments There is evidence that the consumption of sugar is associated with an increased risk of pancreatic carcinoma [24, 26, 27]. Downloaded by: Thieme Verlagsgruppe. Copyrighted material.
However, a possible statistically significant relationship was reported only in women [28]. An increased consumption of milk and milk products does not lead to a risk reduction of pancreatic carcinoma. Recommendation grade: B, evidence level 2b, consensus Comments A connection between milk and cheese consumption and the risk of pancreatic carcinoma was ruled out [7]. However, a protective effect against pancreatic carcinoma was reported for fermented milk products [11]. Since these data pertain only to certain milk products and not to milk and all milk products, a general recommendation cannot be given for this food group. The protective effect of fermented milk products has so far only been proven in a single study. Giving up excessive alcohol consumption may be recommended to reduce the risk of pancreatic carcinoma. Recommendation grade: C, evidence level 3, strong consensus Comments Numerous studies showed no connection between moderate alcohol consumption and pancreatic carcinoma [29 –32]. However, several studies indicate that very high alcohol consumption or binge-drinking may be associated with an increased pancreatic carcinoma risk [32 – 34]. Therefore, it is recommended that alcohol consumption should be limited to a moderate quantity. This is especially the case because increased alcohol consumption may be connected to the pathogenesis of other malignant diseases. It may also result in chronic pancreatic and hepatic diseases. A general renouncement of coffee cannot be recommended. Recommendation grade: B, evidence level 2b, consensus Comments High consumption of coffee (more than three cups per day) was associated with an increased risk of pancreatic carcinoma in several case control studies [35– 37]. This could not be confirmed in several other cohort studies [29, 30, 40] with the exception of two [38, 39]. An increased consumption of tea to reduce the pancreatic carcinoma risk cannot be recommended. Recommendation grade: B, evidence level 2b, consensus Comments In general, there is no connection between tea consumption and pancreatic carcinoma risk [38, 41]. Green tea may possibly have a protective effect on the development of pancreatic carcinoma [4]. In contrast, a cohort study that was done in Japan did not show such a connection [42]. These data may only apply to Europe. Life style Recommendations Recommendations on life style are indicated to reduce the risk of pancreatic carcinoma. Recommendation grade: B, evidence level 2b, consensus Leitlinie 455 Comments Results from family studies show that aside from a genetic component certain life styles are associated with a higher risk of developing pancreatic carcinoma [43, 44]. Especially smoking and obesity have been proven as risk factors for pancreatic carcinoma [45]. This will be described in the following in more detail. Obesity is associated with an increased risk of pancreatic carcinoma. Therefore, excess weight should be avoided. Recommendation grade: A, evidence level 2a, strong consensus Comments A meta-analysis [46], as well as five cohort studies [47 –51], and one case control study [52] found that various obese populations (BMI > 30) had an increased pancreatic carcinoma risk. Thus, a clear connection can be assumed. A general recommendation to encourage exercise to control weight can be given. Recommendation grade: C, evidence level 2b, consensus Comments The results from cohort studies [47, 51, 53] and a case control study [54] indicate a protective effect of exercise on the risk of pancreatic carcinoma. Particularly overweight persons seem to benefit from exercise [47]. However, a detailed recommendation cannot be given, because contradictory results were also found [48], and not all observations and associations were significant [51] or consistent [47]. Avoiding tobacco consumption is recommended to reduce the risk of pancreatic carcinoma. Recommendation grade: A, evidence level 2b, strong consensus Comments Smoking tobacco doubles the risk of pancreatic carcinoma. This relationship is consistently proven by cohort studies [39, 50, 55–57] and case control studies [58, 59]. Individual genetic factors seem to influence the degree of association [60 – 62]. A connection was found even between passive smoking and risk of pancreatic carcinoma [63]. Work-related risk factors Recommendation Contact with pesticides, herbicides, and fungicides may increase the risk of pancreatic carcinoma. Other potential risk factors may be chlorinated hydrocarbons, chromium and chromium compounds, electromagnetic fields, and fuel fumes. Recommendation grade: C, evidence level 2b–3, consensus Comments Some occupational and work areas seem to be associated with a slightly increased disease risk [64 – 66]. The abovementioned chemicals may possibly represent particular risk factors [67– 73]. Drug prophylaxis Recommendation There is at present no drug prophylaxis to reduce the risk of pancreatic carcinoma. Recommendation grade: B, evidence level 2a, consensus Adler G et al. S3-Guideline “Exocrine Pancreatic… Z Gastroenterol 2008; 46: 449–482 Downloaded by: Thieme Verlagsgruppe. Copyrighted material.
Page 1 and 2: S3-Guideline “Exocrine Pancreatic
Page 3 and 4: Table 1 (Fortsetzung) members G. Ba
Page 5: Table 5 Basis for evidence level: C
Page 9 and 10: Other diseases/syndromes which are
Page 11 and 12: Although pancreatic carcinoma may a
Page 13 and 14: Comment Due to the demographic deve
Page 15 and 16: artery and the portal vein and the
Page 17 and 18: KO1-study [196]. The study by Neopt
Page 19 and 20: Gemcitabine/oxaliplatin or gemcitab
Page 21 and 22: Comment The largest amount of data
Page 23 and 24: Drugs to stimulate appetite against
Page 25 and 26: Appendix ! Table 10 Search terms fo
Page 27 and 28: Table 10 (Fortsetzung) search level
Page 29 and 30: 31 Silverman DT. Risk factors for p
Page 31 and 32: 131 Tessler DA, Catanzaro A, Velano
Page 33 and 34: cancer: a phase III trial of the Na

S3-Guideline “Exocrine Pancreatic Carcinoma” 20071 ... - DGVS

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