**13. CP and pancreatic cancer surveillance**

Pancreatic cancer is expected to be the second to third most common cause of cancer-related deaths by 2030 due to late diagnosis and inadequate treatment choices [133]. The relationship between chronic pancreatitis and pancreatic cancer is complicated since common risk factors and the course of the disease affect the rate of malignant transformation [2]. Epidemiological studies have consistently demonstrated an increased risk of pancreatic cancer (i.e., pancreatic ductal adenocarcinoma) in patients with CP, which is thought to be a result of chronic inflammation leading to hyperproliferation of pancreatic stellate cells [134]. In a meta-analysis, the risk of developing pancreatic cancer is increased in patients with chronic pancreatitis, but this is potentially confounded by smoking, which is an independent risk factor [135, 136].

Patients with hereditary pancreatitis have a 70-fold increased risk of developing pancreatic cancer compared to the control population [137, 138]. Patients with tropical pancreatitis can have a relative risk of more than 100; however, recent updates are required to see if there has been a similar decline over time [139].

Patients with hereditary chronic pancreatitis should be screened starting at age 40 or 20 years after the diagnosis of chronic pancreatitis, regardless of gene carrier status.

While PDAC screening is not routinely recommended, it is advised to retain high clinical suspicion in those with unexplained symptoms, such as unexplained weight loss or changes in abdominal pain characteristics [1, 71]. In all patients with chronic pancreatitis, newly diagnosed diabetes may be an early sign of pancreatic cancer and may prompt further research. Unfortunately, the baseline morphological changes in the pancreas (especially the main pancreatic duct dilatation) in CP make it difficult to recognize a small neoplasm in cross-sectional imaging. In patients with multiple calcifications which may mask changes in the parenchyma, there is a chance of sampling error with EUS-guided fine needle aspiration [1].
