But as I originally stated, CA-125 is raised in ANY pleural effusion,
ANY ascites - and in a woman those "could" be the result of Ca ovary.
I'm sure all are aware of
J.Roy.Soc.Med 2001; 94: 981 and J.Roy.Soc.Med 1997; 90: 448 for
two examples of misleading Ca125 values in presence of ascites.
There are also numerous reports of elevated CA-125 and ascites
associated with hypothyroidism and I've also seen it in cases of
pericardial effusion.
I've already been contacted by our chest physicians about measuring
CA125 when they've got pleural effusions of no known aetiology.
This guidance will lead to patients being referred to oncologists and
undergoing unnecessary, expensive, investigations.
In times when the NHS is having major budget cuts forced upon it, to
recommend misleading tests is reckless.
If we can only allow it through specialist MUO units it may be somewhat
restricted, but the facts above remain true even for specialist
clinicians.
Perhaps we could have a National Audit of its usefulness after about 6
months, though by that time it will have become so entrenched as to be
unstoppable.
On a more positive note: I see no recommendations for measuring CEA in
the investigation of abdominal conditions. Can we therefore stop doing
all these requests?
What about Ca19-9 and Ca15-3? We're forever being asked for these tests
(which we currently don't offer).
Yours in sadness
Michael
-----Original Message-----
From: Clinical biochemistry discussion list
[mailto:[log in to unmask]] On Behalf Of Dr C M Sturgeon
Sent: 03 September 2010 14:35
To: [log in to unmask]
Subject: Re: CA-125 in Malignancy of Unknown Origin
Dear Colleagues
Thank you very much for the opportunity to publicize the NICE Guidelines
on Metastatic malignant disease of unknown primary origin (MUO) which
are
now available on the NICE website [www.nice.org.uk].
Recommendations concerning tumour markers were very carefully considered
by the NICE Guideline Development Group, of which we were privileged to
be members.
The Guidelines clearly state that tumour markers are special diagnostic
tests (p.12 of Quick Reference Summary) and that their measurement in
patients with metastatic malignancy disease of unknown
primary origin (i.e. MUO) should be requested by the specialist MUO
clinical team ONLY and as follows:
AFP and hCG in presentations compatible with germ-cell tumours
(particularly mediastinal and/or retroperitoneal masses and in young
men).
AFP in presentations compatible with hepatocellular cancer.
PSA in presentations compatible with prostate cancer.
CA125 in presentations compatible with ovarian cancer (including
inguinal node, chest, pleural, peritoneal or retroperitoneal
presentations). Carefully interpret the result because of limited
test specificity.
All the evidence and decision-making can be found in the accompanying
guidance.
These recommendations are not an invitation for indiscriminate
requesting of tumour markers and we believe they are in accord with
recommendations in the BMJ article on "Serum tumour markers: how to
order and interpret them"
[http://www.bmj.com/content/339/bmj.b3527.long].
Hoping the above is helpful and with best wishes to all,
Cathie Sturgeon Andy Fowell
Member, NICE GDG on MUO Chair, NICE GDG on MUO
& Consultant Clinical Scientist & Macmillan Consultant
in
Dept of Clinical Biochemistry Palliative Medicine
Royal Infirmary of Edinburgh Eryri Hospital
Edinburgh EH16 4SA NW Wales NHS Trust
Tel: 0131 242 6885 Tel: 01286 662775
[log in to unmask] [log in to unmask]
Jonathan Kay wrote:
> How about writing to the NICE project manager for that guidance and
> asking for the support for that particular recommendation. (I've had a
> look and can't find it in their documents on the web.) IMHO NICE does
> well at publishing its working.
>
> Jonathan
>
>
>
> On 3 Sep 2010, at 11:44, Colley, Michael wrote:
>
>> I'm surprised Tim Reynolds hasn't given us his thoughts after his
>> study a few years ago.
>>
>> The amount this is going to cost the NHS is phenomenally large.
>>
>> Is there any appeal against NICE?
>>
>> M.
>>
>> *From:* Clinical biochemistry discussion list
>> [mailto:[log in to unmask]] *On Behalf
>> Of *Mainwaring-Burton Richard (South London Healthcare NHS Trust)
>> *Sent:* 03 September 2010 09:18
>> *To:* [log in to unmask]
>> <mailto:[log in to unmask]>
>> *Subject:* Re: CA-125 in Malignancy of Unknown Origin
>>
>> Perhaps a standard e-mail could be devised by a dignitary who rides
>> the "tumour monitor" hobby-horse which all the subscribers can then
>> forward to NICE at oncewith the BMJ reference attached.
>>
>> with best wishes
>> Richard
>> Richard Mainwaring-Burton
>> Consultant Biochemist
>> South London Healthcare Trust
>> Queen Mary's Hospital
>> Sidcup, Kent, DA14 6LT
>> 020-8308-3084
>> mob: 07831-739876
>>
------------------------------------------------------------------------
>>
>> *From:* Clinical biochemistry discussion list
>> [[log in to unmask]] On Behalf Of John Francis Doran
>> (ABM ULHB - Biochemistry) [[log in to unmask]]
>> *Sent:* 02 September 2010 18:16
>> *To:* [log in to unmask]
>> <mailto:[log in to unmask]>
>> *Subject:* Re: CA-125 in Malignancy of Unknown Origin
>>
>> As Alex in "A Clockwork Orange" would say, "It's Yarbles". Given the
>> article in the BMJ last year, I am surprised that the Guideline
>> Development Group included Cathy Sturgeon.
>> We are plagued with requests for multiple Tumour markers with
>> clinical details such a "weight loss", against all the evidence. What
>> hope do we have when NICE appear to be condoning such an approach.
>> How about all writing to NICE to express our disagreement.
>> John Doran
>>
------------------------------------------------------------------------
>>
>> *From:* Clinical biochemistry discussion list
>> [mailto:[log in to unmask]] *On Behalf Of *Colley,
Michael
>> *Sent:* 02 September 2010 11:42
>> *To:* [log in to unmask]
>> <mailto:[log in to unmask]>
>> *Subject:* CA-125 in Malignancy of Unknown Origin
>>
>> To all the informed people out there - I sent this out a couple of
>> weeks ago but not one reply or comment was seen.
>> Did it get lost in the ether, or is everyone away on holiday?
>> Suggestions would be appreciated.
>>
>>
>> The new NICE guidelines on malignancy of unknown origin recommend
>> measuring CA125 in patients with ascites:
>>
>> 1.2.1.1 includes
>>
>> Measure
>>
>> * cancer antigen 125 (CA125) in women with peritoneal malignancy
>> or ascites (see recommendation 1.2.2.1)
>>
>> However, as CA-125 is increased in ascites and pleural effusion (and
>> pericardial effusion) of any cause this is surely going to mislead
>> clinicians. I've seen it over 1000 in patients with ascites of
>> liver failure (yes, we measured it just to prove the point!)
>>
>> Does anyone know where this recommendation came from? Has anyone got
>> references to any good studies showing that this is useful?
>>
>>
>> Tumour markers
>>
>> 1.2 .2.1 Do not measure tumour markers during diagnosis except
for:
>>
>> * AFP and hCG in patients with presentations compatible with
>> germ-cell tumours (particularly those with mediastinal and/or
>> retroperitoneal masses and in young men).
>> * AFP in patients with presentations compatible with
>> hepatocellular cancer.
>> * PSA in men with presentations compatible with prostate cancer.
>>
>> * CA125 in women with presentations compatible with ovarian
>> cancer (including those with inguinal node, chest, pleural,
>> peritoneal or retroperitoneal presentations). Carefully interpret the
>> results because of limited test specificity.
>>
>> At least this guideline suggests we shouldn't be doing CEA as a
>> diagnostic test - well we knew that anyway even if the clinicians
>> didn't. No doubt they'll be wanting CEA despite the
recommendation.
>>
>> Michael
>>
>> Dr. C . M. Colley
>> Consultant Chemical Pathologist
>> Great Western Hospital
>> Swindon SN3 6BB
>>
>>
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