This AGA Clinical Practice Update is an expert review, not a systematic review, so its best practice advice statements carry no formal grading of evidence. It addresses a gap: guidelines say who to survey but rarely when to stop.
For incidental pancreatic cystic lesions (PCLs), it advises counselling against routine surveillance in people with significant comorbidity (an age-adjusted Charlson index of about 3 to 5 or more), particularly for low-risk lesions. In people over 65 with lesions of 15 mm or less that have been stable for 5 years, with no worrisome features, stopping can be considered after detailed shared decision-making. Over 75, with lesions under 30 mm stable for 5 years, a detailed discussion about the questionable value of continuing is advised. Development of comorbidity that would preclude surgery should prompt a discussion about stopping.
For hepatocellular carcinoma (HCC), it advises that antivirals lower but do not remove risk, and that surveillance in viral hepatitis should follow fibrosis stage and risk rather than age. Surveillance should be considered in older adults with cirrhosis of any cause unless life expectancy is below 1 to 2 years, and should stop when it is, as in Child-Turcotte-Pugh C disease without a transplant option. This is expert opinion and does not override existing guidelines on who should be under surveillance.
- Review the age, comorbidity and life expectancy of every patient on long-term cyst or HCC surveillance.
- For stable cysts of 15 mm or less after 5 years in people over 65, consider stopping after shared decision-making.
- Consider HCC surveillance in older adults with cirrhosis unless life expectancy is under 1 to 2 years.
- Document the reason and the discussion when surveillance is stopped.
Why it matters
Surveillance with no end point carries potential harms as well as benefits, and these statements put limits on it.
Don't overread it
The statements are expert opinion without formal evidence grading and are US-based; they do not replace specialist judgement in an individual patient.
The statistics, in plain English
These statements come from expert review, so they have no confidence intervals or strength ratings. The age and size cut-offs are judgement-based and should be applied with the patient's own risks and wishes in mind.
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