Is post-endoscopic ultrasound pancreatic cancer analogous to post-colonoscopy colorectal cancer?

We congratulate King et al. for their recent paper and for coining the term “post-endoscopic ultrasound pancreatic cancer (PEPC)” [1]. We would however like to draw your attention to a few observations, as elaborated below. The authors propose PEPC to be analogous to post-colonoscopy colorectal cancer (PCCRC). This analogy may not be accurate for two main reasons. Firstly, endoscopic ultrasound (EUS) is not used for population-based screening in average risk individuals. Secondly, in individuals with a clinical suspicion of carcinoma of the pancreas, EUS is always supported by multimodality evaluation, including tissue acquisition. EUS is a twodimensional imaging modality and augments cross-sectional imaging, mostly when tissue is being obtained (i. e. to confirm the diagnosis). Therefore, pancreatic cancer that was missed by the initial evaluation should not be considered to be a failure of EUS, but a failure of multimodality evaluation to detect the lesion. This is in contrast to colonoscopy, which, as a standalone procedure, is considered sufficient to rule out carcinoma of the colon. The authors assume that, if a diagnosis of carcinoma of the pancreas was coded within 6 months of the EUS, the diagnosis was made by EUS; if made between 6 and 18 months, the diagnosis was missed by EUS.We believe this assumption is completely arbitrary and not firmly grounded in science. With existing guidelines for pancreatic cancer screening recommending yearly screening when there are no concerning lesions on the index evaluation and an interval as short as 3 months for high risk lesions [2], the classifications proposed by the authors do not correspond with the available literature. We value the contributions of the authors in improving key performance measures in endoscopy with respect to missed cancer diagnosis. We, however, request that EUS assessments have to be considered in conjunction with other imaging modalities in the diagnosis of carcinoma of the pancreas.