A 52-year-old man comes to the physician for a regular health check-up. He is a chronic smoker and has consumed 1 to 2 beers 2 to 3 times a week for the past 10 years. He also drinks 6 to 7 cups of coffee daily. The patient was diagnosed with type 2 diabetes mellitus 5 years ago and takes metformin. Blood pressure is 130/80 mm Hg and body mass index is 29 kg/m². Random blood sugar is 190 mg/dL. His older brother died of pancreatic cancer at age 58, and the patient is worried that he might also develop pancreatic cancer. Which of the following interventions would have the greatest impact on decreasing this patient's risk of pancreatic cancer?

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11ec25c8_d272_fa36_bc81_5570e1b0ae99_MD0003_00 Pancreatic cancer is the 4th leading cause of cancer deaths in the United States. Adenocarcinoma is the most common tissue type. Pancreatic cancer usually occurs after age 45 and is more common in men and African American patients. However, it is usually diagnosed relatively late in the disease course and has a high mortality rate (98% in some studies). The major hereditary risk factors for pancreatic cancer include first-degree relatives with pancreatic cancer, hereditary pancreatitis, and germline mutations (eg, BRCA1, BRCA2, Peutz-Jeghers syndrome). Environmental risk factors include cigarette smoking, nonhereditary chronic pancreatitis, and obesity with low physical activity. Cigarette smoking is the most consistent reversible risk factor for pancreatic cancer. The risk of cancer increases significantly with the number of cigarettes consumed, and heavy smokers have nearly 2-3 times higher risk than nonsmokers. Some studies estimate that smoking cessation could reduce pancreatic cancer deaths by 25%. (Choices A and D) Long-standing diabetes is a risk factor for pancreatic cancer, and conversely, new-onset diabetes is often a sign of occult pancreatic cancer. The effect of diabetic treatment on pancreatic cancer risk is variable; insulin and insulin secretagogues (eg, sulfonylureas) are associated with an increased risk, whereas metformin is associated with a lower risk. Neither discontinuing metformin nor initiating insulin would be likely to lower this patient's cancer risk, regardless of improved glycemic control. (Choices B and C) Studies have not shown a significantly decreased incidence of pancreatic cancer with alcohol or caffeine reduction. Heavy alcohol use can lead to chronic pancreatitis, which is associated with a slightly higher risk of pancreatic cancer. However, this is not as significant as the association between smoking and pancreatic cancer. In addition, this patient is not a heavy alcohol consumer. Educational objective: Pancreatic cancer can be due to hereditary (eg, first-degree relative with pancreatic cancer, hereditary pancreatitis) or environmental (eg, cigarette smoking, obesity) risk factors. Cigarette smoking is the most consistent reversible risk factor for pancreatic cancer. References: Cigarette smoking and pancreatic cancer: an analysis from the International Pancreatic Cancer Case-Control Consortium (PanC4). (http://www.ncbi.nlm.nih.gov/pubmed/22104574) The epidemiology of pancreatitis and pancreatic cancer. (http://www.ncbi.nlm.nih.gov/pubmed/23622135) Alcohol intake and pancreatic cancer: a pooled analysis from the Pancreatic Cancer Cohort Consortium (PanScan). (http://www.ncbi.nlm.nih.gov/pubmed/20373013)

A 52-Year-Old Man Comes to the Physician for a Regular