Detecting circulating tumor material and digital pathology imaging during pancreatic cancer progression

Table 3 Challenges and potential solutions for pancreatic cancer diagnosis and treatment

Challenges	Potential solutions
Metastatic probability increases dramatically with larger tumor size	Promote development of early detection methods (circulating tumor cells, extracellular vesicles, molecular cargo in CTCs and EVs, cfDNA, ctDNA)
Tumor mutations develop up to two decades with metastatic mutations occurring late in the process	Identify founder mutations that correlate with unusual survival outcomes
Pancreatic stroma influences treatment sensitivity	Promote research on stromal characterization
Transporter expression in the tumor impacts drug delivery	Identify expression features that correlate with treatment sensitivity to a variety of drugs
CA 19-9 is not pancreatic cancer specific	Promote development of assays for biomarker panels that increase CA 19-9 utility that will be eligible for FDA approval
Prediction of resectability is only 70%-85% accurate	Improve staging based on biopsies by implementing clinical use of digital pathology methods
No FDA-approved digital pathology methods exist for pancreatic cancer	Combine digital pathology with accepted primary diagnostic methods and test special controls for digital imaging that will permit FDA application through a more streamlined de novo pathway

CTC: Circulating tumor cells; EVs: Extracellular vesicles; cfDNA: Circulating free DNA; ctDNA: Circulating tumor DNA; FDA: Food and Drug Administration.