Shared Decision-Making in IPMN of the Pancreas: A Framework for Surgical Decisions Under Uncertainty.

BACKGROUND

Management of intraductal papillary mucinous neoplasms (IPMNs) requires choosing between surgical resection and active surveillance, yet current diagnostic tools cannot reliably distinguish which lesions harbor high-grade dysplasia or invasive cancer. As a result, many patients undergo major pancreatic surgery for low-grade disease, while others are observed until progression emerges. This uncertainty contributes to substantial variation in surgeon risk estimates, intervention thresholds, and treatment recommendations. Patients likewise differ in their tolerance for cancer risk, views on surgical morbidity, perceived burden of ongoing surveillance, and desired role in decision-making, making IPMN a distinctly preference-sensitive clinical scenario. Although recent international guidelines acknowledge the importance of incorporating patient values into management decisions, practical frameworks for doing so remain underdeveloped.

METHODS

We performed a narrative review of the literature examining sources of uncertainty in IPMN management, variation in surgeon and patient risk perception, and existing approaches to shared decision-making (SDM) in preference-sensitive surgical decisions. We also evaluated communication strategies and decision-support tools relevant to improving decision quality in the setting of uncertain malignant potential.

RESULTS

Evidence demonstrates substantial heterogeneity in both clinician and patient interpretation of malignancy risk, operative morbidity, and acceptable thresholds for surgical intervention. Surgeons and patients often weigh competing risks diff erently, contributing to variation in management recommendations even when clinical characteristics are similar. SDM provides a structured approach to integrating individualized malignancy risk estimates, discussion of treatment trade-off s, and elicitation of patient values. Conceptual frameworks and emerging decision-support tools suggest that SDM may improve calibration of risk perception, reduce unwarranted variation in care, and enhance alignment between treatment decisions and patient preferences.

CONCLUSIONS

IPMN management represents a high-stakes clinical decision made under conditions of incomplete information. SDM off ers a pragmatic strategy to integrate clinical evidence with patient values when choosing between resection and surveillance. Incorporating SDM into routine IPMN care may improve decision quality, promote transparency in risk communication, and support more patient-centered recommendations while preserving clinical judgment.