If I am to understand this your lab would have
refused the GP's request even if he had written 'CA-126 to exclude
ovarian cancer. Clinical picture in keeping with it, ifraised I will
send for US and DGH referal'.
So you are really saying is there
are no circumstances you would allow the GP to have it as he and the
staff at the DGH did not know other things can cause ascites and high
CA-125 (you are forgetting the abnormal US before the DGH staff
proceded). Who knows why they chose to do a laparoscopy but we can not
judge and it was not the GPs decision.
All I am saying is that
there are consequences to our choices as lab professionals We are
trained to see the effects of overordering but have not a lot of
information on the effects of not allowing the tests and so are biased
in our analyses of the good or bad we do by restricting tests without
training or discussions with the people we restrict them
on.
Elizabeth
On Jun 30, 2009, at 6:26 AM,
"Loughrey, Clodagh" <
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]>
wrote:
> If I am judging anything (and I work in a cancer
hospital too), it is only the lack of resources which limit the
education some of our front line staff receive on appropriate use of
tumour markers. We agree that the GP was quick to pick up that this lady
wasn't well and that there is no single 'right' way of proceeding
thereafter, we all investigate as we feel intuitively best after history
and examination. He knows now (as do the DGH doctors) that ovarian
cancer is not the only cause of ascites and a raised CA 125. Intuition,
like tumour markers, can of course be exceedingly useful but both need
to be used with full awareness of limitations of specificity and
sensitivity.
>
> In answer to Jonathan's question, it is
not money making me stall this request, so I would not act differently
if it cost nothing extra to do. Thank goodness UK labs are not (yet)
black boxes and are allowed to (expected to? there's another thread...)
provide added value by way of appropriate interpretative advice.
>
> All the best
>
> Clodagh
>
>
-----Original Message-----
> From: Elizabeth MacNamara [mailto:
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]]
>
Sent: 29 June 2009 19:28
> To: Loughrey, Clodagh
> Cc:
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]>
Subject: Re: CA-125
>
>
> I would like to give you
another end to the tale which also happens. Let us suppose the woman had
ovarian cancer and the quick workup of
> the doctor ensured she
got to see the gynaecologist in less than 6
> months. How would
you feel about the workup?I guess the difference
> between our
approach is I get to see lots of patients with cancer and
> I
often wish the doctors had followed their intuition and did a
better
> work-up. If this patient had had ovarian cancer and the
doctor had
> just referred her to a hepatologist for workup of
ascites due to her
> heavy alcohol consumption how would you judge
him.
>
> The problem is only the doctor knows what he saw
when he met the
> patient. He was right not to just assume because
she drank she could
> only have liver disease. Which brings me
back to we should be a little
> slower to judge the practicing
physicians and nurses who are the front
> line that get to see the
whole patient and not just their serum. They
> get humanity, we
usually get the blood and often make our judgements
> when we have
the results on the computer.
>
> However, I can see in
essentials we agree
>
> Elizabeth
>
>
>
On Jun 29, 2009, at 1:17 PM, "Loughrey, Clodagh" <
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]>>
wrote:
>
>> As you say it is much easier with the
retrospectoscope, but even
>> with this story I don't think I
would have requested any tumour
>> markers as part of first
line investigation. USS abdomen (and maybe
>> pelvis) would
probably have featured early, after some routine
>> laboratory
testing. The message that many GPs haven't received is
>> that
CA-125 isn't diagnostic of anything at all and that it is
not
>> very helpful used in this way, indeed potentially quite
the reverse.
>> In this case I feel it directed the GP to
misdirect the radiologist
>> on the USS form.
>>
>> But back to the question of whether the lab should have
done it in
>> the first place with that information, which is
essentially the
>> scenario that Wayne described
initially? I don't think it is good
>> practice to refuse
any request outright and we don't have the
>> resources to vet
all requests coming in; John's or Mike's
>> suggestions may
have helped avoid going down the wrong route in this
>>
case.
>>
>> Best wishes
>>
>>
Clodagh
>>
>> -----Original Message-----
>>
From: Elizabeth MacNamara [mailto:
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]]
>>
Sent: 29 June 2009 17:41
>> To: Loughrey, Clodagh
>>
Cc:
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]>>
Subject: Re: CA-125
>>
>>
>> You are
looking at something with 20-20 hindsight and indeed the
>>
outcome was terrible but what are you suggesting was wrong? The GP
was
>> right to include ovarian cancer as part of the workup
and obviously
>> asked the right question on th US request. The
reason the patient went
>> for laparoscopy is not known but I
do not see anything wrong with the
>> request for CA-125 and I
believe the GP was the sort of GP we would
>> all want to have
on the information you have supplied.
>>
>> Elizabeth
Mac Namara
>>
>>
>>
>> On Jun 29,
2009, at 11:08 AM, "Loughrey, Clodagh"
>> <
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]>>>
wrote:
>>
>>> I have seen this happen: 42 year old
lady with general malaise and
>>> weight loss and abdominal
bloating gets a CA-125 requested by GP and
>>> on finding it
elevated he requests pelvic ultrasound, writing
>>>
'probably ovarian Ca' on the request form. Radiologist sees
ascites
>>> but 'can't exclude small ovarian lesion' and she
is transferred from
>>> DGH to teaching hospital for
laparotomy and probable bilateral
>>> oophorectomy. Referral
for TPN just before surgery resulted in the
>>> finding that
she put away about 10 bottles of wine a week and had
>>>
liver cirrhosis..
>>>
>>>
Clodagh
>>>
>>> CM Loughrey MD MRCP
FRCPath
>>> Consultant Chemical Pathologist
>>>
Belfast City Hospital
>>>
>>>
>>>
-----Original Message-----
>>> From: Clinical biochemistry
discussion list [mailto:ACB-CLIN-CHEM-
>>>
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]] On Behalf Of
Frater John (RVW) Pathology
>>> Sent: 29 June 2009
14:33
>>> To:
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]>>>
Subject: Re: CA-125
>>>
>>>
>>>
Not only may finding an increased result for CA125 cause anxiety
for
>>> the patient, it may (and has been known to) lead to
incorrect
>>> clinical care of the patient, when the
increased CA125 is due to a
>>> cause other than ovarian
cancer. Clearly, missing the diagnosis of
>>> ovarian
cancer is dreadful, but the incorrect management of the
>>>
patient's condition can also have serious adverse
consequences.
>>> Having said that, providing a suitable
comment on the report,
>>> highlighting the possibility that
increased CA125 may be due to other
>>> causes, may help
avoid inappropriate action.
>>>
>>> With regard
to the cost involved, I believe we should take some
>>>
responsibility for the sensible use of NHS funds even though it
is
>>> not "our money". How we respond to requests
should primarily be
>>> about quality of care, but costs are
relevant to our service
>>> provision, though perhaps not
easy to decide their significance when
>>> dealing with
individual requests?
>>>
>>>
John
>>>
>>> -----Original
Message-----
>>> From: Clinical biochemistry discussion list
[mailto:ACB-CLIN-CHEM-
>>>
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]] On Behalf Of
Douglas Thompson
>>> Sent: 29 June 2009
12:34
>>> To:
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]>>>
Subject: Re: CA-125
>>>
>>>
>>>
Sorry Tim, cannot agree with this approach. We should be looking
at
>>> the evidence and acting
appropriately.
>>>
>>> The evidence is that it
is not helpful to do Ca 125 in this scenario.
>>> Ca 125 is
not a diagnostic test and to do it may only result in
>>>
increased patient anxiety when an elevated Ca 125 is
reported.
>>>
>>> Best wishes
>>>
>>> Douglas
>>>
>>>
>>> Dr D Thompson
>>> Principal
Biochemist
>>> Clinical Biochemistry and
Immunology
>>> The General Infirmary
>>>
Leeds LS1 3EX
>>> Tel 0113 3926503
>>>
>>> Please visit our web-site at
www.leedsteachinghospitals.com
>>>
>>>>>> Reynolds Tim <
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]>
29/6/09 10:25
>>>>>>>>>
>>>
Personally, I would never refuse such a request because I have
not
>>> seen the patient. It may be safe to reject them but
when a patient
>>> has the test rejected and then in 3 years
time is diagnosed with
>>> ovarian cancer, you will have a
hard job fighting the local press.
>>> So, since PCTs are
billed for the tests they have done, and its not
>>> your
money, it is always safer to just do the test...
>>>
>>>
>>> TIM
>>>
>>>
>>>
>>>
>>> ***
>>>
*********************************************************************
>>>
*************
>>> Prof. Tim Reynolds,
>>>
Queen's Hospital,
>>> Belvedere Rd,
>>>
Burton-on-Trent,
>>> Staffordshire,
>>> DE13
0RB
>>>
>>> work tel: 01283 511511 ext.
4035
>>> work fax: 01283 593064
>>> work email:
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ymailto="mailto:[log in to unmask]">
[log in to unmask]>>>
home email:
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[log in to unmask]>>>
***
>>>
*********************************************************************
>>>
**************
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>>> -----Original
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>>> From: Clinical
biochemistry discussion list [mailto:ACB-CLIN-
>>>
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]] On
Behalf Of Bradbury Wayne
>>> (RNL) North Cumbria University
Hospitals
>>> Sent: 29 June 2009
10:14
>>> To:
[log in to unmask]"
ymailto="mailto:[log in to unmask]">
[log in to unmask]>>>
Subject: CA-125
>>>
>>>
>>>
>>> Hello
all,
>>>
>>>
>>>
>>> Is anybody else seeing a surge in
requests from primary care
>>> for CA-125 on
women
>>>
>>> with
"Abdominal bloating ?ovarian malignancy?"
>>>
>>>
>>>
>>> I
think this is related to an article in the BMJ on 4th
June
>>> where a patient suggests her late
>>>
>>> diagnosis of ovarian cancer could
have been prevented if only
>>> her GP had asked for a
CA-125.
>>>
>>>
>>>
>>>
http://www.bmj.com/cgi/content/full/338/jun04_2/b2072>>>
>>>
>>>
>>> I
am declining these requests. Am I wrong?
>>>
>>>
>>>
>>>
Wayne Bradbury.
>>>
>>>
>>>
>>>
>>>
>>>
Mr WH Bradbury
>>>
>>>
Consultant Biochemist
>>>
>>>
Biochemistry Department
>>>
>>>
Cumberland Infirmary
>>>
>>> CARLISLE
>>>
>>> Cumbria
>>>
>>> CA2 7HY
>>>
>>> Tel: 01228
814521
>>>
>>> Fax:
01228 814831
>>>
>>>
E-mail:
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[log in to unmask]>>>
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>>>
>>>
>>>
>>>
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