Comprehensive strategies for the diagnosis of pancreatic cancer were evaluated with decision analysis for accuracy, cost, and invasiveness. An optimal strategy began with ultrasonography followed by a combination of computerized tomography, needle aspiration biopsy, endoscopic retrograde cholangiopancreatography, and laparotomy. The refined strategy established or excluded the diagnosis of pancreatic cancer with sufficient reliability for clinical decisions. This strategy had an overall sensitivity of 92% and specificity was greater than 99%. The number of invasive tests increased with the prevalence of disease in the population, but the frequency of diagnostic laparotomy was only 1-9%. The comprehensive strategy could not be significantly improved without marked increases in the utilization of invasive technology.
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