Thanks to everyone who has contributed to this debate, it has been interesting.
For the record we store any samples not tested for 7 days so that requestors have the opportunity to supplement the information provided on the request form.
Of the CA-125 requests from primary care not tested I add the comment "If ovarian cancer is suspected suggest refer under the two week rule to Consultant Gynaecologist".
I am encouraged that quite a few people do something similar to me and all those years studying for FRCPath were worthwhile.
I am surprised that so many labs think it's wrong to decline inappropriate requests.
In my part of the world consultants in pathology are encouraged to control demand
as workload continues to grow by an unsustainable 10% per annum.
In contrast primary care is being incentivised to take on more work and reduce referrals to secondary care. I think this is contributing to a rise in inappropriate requesting in primary care.
Wayne.
-----Original Message-----
From: Clinical biochemistry discussion list [mailto:[log in to unmask]] On Behalf Of Loughrey, Clodagh
Sent: 29 June 2009 18:18
To: [log in to unmask]
Subject: Re: CA-125
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]]
Sent: 29 June 2009 17:41
To: Loughrey, Clodagh
Cc: [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]
> 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]] On Behalf Of Frater John (RVW) Pathology
> Sent: 29 June 2009 14:33
> To: [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]] On Behalf Of Douglas Thompson
> Sent: 29 June 2009 12:34
> To: [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]> 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,
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> Staffordshire,
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>
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> -----Original Message-----
> From: Clinical biochemistry discussion list [mailto:ACB-CLIN-
> [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]
> 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]
> <mailto:[log in to unmask]>
>
>
>
>
>
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