Putting in my pennyworth......
 
We have seen an increase in CA-125 requests, largely as a result of patient pressure.  If patients read that CA-125 has been shown to be useful in diagnosing ovarian cancer it is very difficult for a GP to refuse the test.  I also feel that our role is to support and help our colleagues in primary care.  We will therefore do CA125 requests from GPs but add a comment to all reports: if the result is 'normal' we add a comment that this is not a good test for ovarian cancer and may be normal in 50% of patients with Stage 1 disease, so a 'normal' result does not exclude ovarian malignancy and any suspicion of ovarian malignancy must be followed up by ultrasound and pelvic examination.  If the result is high we add a comment to say that CA125 is raised in a variety of benign gynaecological diseases, such as endometriosis, add that it is raised in non-ovarian malignancies and in ascites from any cause.  
 
I feel that both educates the GP (and the patient); we have not refused to do a test which may be of clinical benefit and which may benefit the patient.  This policy has been dicussed with local GPs who find it both education and helpful as they can show our comment to the patient and then dicuss the result/next step.
 
Although I support demand management by reducing duplicate tests and not doing tests which have no clinical value, I feel quite strongly that we cannot make a clinical judgement about a test in isolation in the lab. 
 
I'll now go back to my semi-retirement!
 
Cathryn
 
Cathryn Corns
Head of Biochemistry Department
01702 435555  ext 6614
 

From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Rebecca Edwards
Sent: 30 June 2009 16:00
To: [log in to unmask]
Subject: Re: CA-125 / whose test

Elizabeth,
 
Your hypothetical clinical details "CA-125 to exclude ovarian cancer. Clinical picture in keeping with it, if raised I will send for US and DGH referal" would be exactly what would worry me.  CA-125 cannot be used to exclude ovarian cancer as it is not sensitive enough. Were the GP to decide NOT to refer based on a negative result this could have life-threatening consequences for the patient. 
 
My personal feeling is that the results should be reported, but alongside that should be a comment clarifying the uses and pitfalls of the test.
 
 
Rebecca
 

--- On Tue, 30/6/09, Elizabeth MacNamara <[log in to unmask]> wrote:

From: Elizabeth MacNamara <[log in to unmask]>
Subject: Re: CA-125 / whose test
To: [log in to unmask]
Date: Tuesday, 30 June, 2009, 2:09 AM

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: [log in to unmask]" ymailto="mailto:[log in to unmask]">[log in to unmask]
>>> home email: [log in to unmask]" ymailto="mailto:[log in to unmask]">[log in to unmask]
>>> ***
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>>>      -----Original Message-----
>>>      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: [log in to unmask]" ymailto="mailto:[log in to unmask]">[log in to unmask]
>>> <mailto:[log in to unmask]" ymailto="mailto:[log in to unmask]">[log in to unmask]>
>>>
>>>
>>>
>>>
>>>
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