A study to evaluate the use of CA125 in ovarian cancer follow-up: A change in practice led by patient preference

Evaluation of follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

This is an update of a previous Cochrane Review, last updated in 2014. Ovarian cancer is the eighth most common cancer and seventh most common cause of death due to cancer in women worldwide. Traditionally, most women who have been treated for cancer undergo long-term follow-up in secondary care. However, it has been suggested that the use of routine review may not be effective in improving survival, or health-related quality of life (HRQOL), or relieving anxiety. In addition, traditional follow-up may not be cost-effective.

OBJECTIVES

To compare the potential effects of different strategies of follow-up in women with epithelial ovarian cancer, following completion of primary treatment.

SEARCH METHODS

For this update, we searched the Cochrane Gynaecological Cancer Group Trials Register, CENTRAL 2022, Issue 11, MEDLINE, and Embase from August 2013 to November 2022. We also searched review articles and contacted experts in the field.

SELECTION CRITERIA

All randomised controlled trials (RCTs) that evaluated follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

We followed standard Cochrane methodology. Two review authors independently selected potentially relevant trials, extracted data, and assessed risk of bias. They compared results, and resolved disagreements by discussion. We assessed the certainty of evidence, using the GRADE approach, for the outcomes of interest: overall survival (OS), health-related quality of life (HRQOL), psychological effects, and cost analysis.

MAIN RESULTS

For this update, we included one new RCT, including 112 women with ovarian, fallopian tube, or peritoneal cancer, who had completed primary treatment by surgery, with or without chemotherapy. This study reported the effect of individualised, i.e. individually tailored, nurse-led follow-up versus conventional medical follow-up on HRQOL, psychological outcomes, and cost-analysis. Individualised follow-up improved HRQOL in one of the two scales, with a decrease in mean difference (MD) in the QLQ-C30 discomfort scale following 12 months of individualised treatment compared to 12 months of conventional treatment (MD -5.76 points, 95% confidence interval (CI) -10.92 to -0.60; 1 study, 112 participants; low-certainty evidence; minimal important difference 4 to 10 points). There may be little or no difference in the other HRQOL scale (QLQ-Ov28, MD -0.97 points, 95% CI -2.57 to 0.63; 1 study, 112 participants: low-certainty evidence); psychological outcome, measured with the hospital anxiety and depression scale (HADS; MD 0.10 point, 95% CI -0.81 to 1.02; 1 study, 112 participants: low-certainty evidence), or cost analysis (MD -GBP 695.00, 95% CI -1467.23 to 77.23; 1 study, 112 participants: moderate-certainty evidence). Our previous review included one RCT, with 529 women in a confirmed remission, with normal CA125 concentration and no radiological evidence of disease, after surgery and first-line chemotherapy for ovarian cancer. This study evaluated immediate treatment of ovarian cancer relapse following a rise of serum CA125 levels versus delaying treatment until symptoms developed for OS, and HRQOL. There was little or no difference in OS between the immediate and delayed arms after a median follow-up of 56.9 months (unadjusted hazard ratio (HR) 0.98, 95% CI 0.80 to 1.20; 1 study, 529 participants; moderate-certainty evidence). Time from randomisation to first deterioration in global health score or death was shorter in the immediate treatment group than in the delayed treatment group (HR 0.71, 95% CI 0.58 to 0.88).

AUTHORS' CONCLUSIONS

Limited evidence from one trial suggests that routine surveillance with CA125 in asymptomatic women and treatment at CA125-defined relapse does not seem to offer survival advantage when compared to treatment at symptomatic relapse. However, this study pre-dates the use of PARPi maintenance treatment and the increased use of secondary cytoreductive surgery, so the results may be limited in their applicability to current practice. Limited evidence from one trial suggests that individualised nurse-led follow-up may improve HRQOL in women with ovarian cancer following completion of primary treatment. Large RCTs are needed to compare different types of follow-up, looking at survival, HRQOL, psychological effects, and cost as outcomes.

[Follow-up of patients treated for an epithelial ovarian cancer, place of hormone replacement therapy and of contraception: Article drafted from the French Guidelines in oncology entitled "Initial management of patients with epithelial ovarian cancer" developed by FRANCOGYN, CNGOF, SFOG, GINECO-ARCAGY under the aegis of CNGOF and endorsed by INCa]

OBJECTIVES

To define follow-up modalities after an epithelial ovarian, tubal or primitive peritoneal cancer. To define possibilities of hormone replacement therapy (HRT) and contraceptive use after treatment.

METHODS

Systematic review of the literature in French and English langage conducted on Pubmed/Medline and the Cochrane Library.

RESULTS

After the treatment of an epithelial ovarian, tubal or primitive peritoneal cancer, symptoms evaluation for follow-up is recommended at 3 months, 6 months, 12 months, 18 months, 24 months, and then yearly (Grade B). Only patients with an initial complete surgery (CC0, without any macroscopic signs of disease), and with a good general condition (ECOG 0) should be followed with paraclinic tests, with a serum HE4 or CA125 concentration measurement, from 6 months after the end of treatments (GradeC). Systematic follow-up with CT of the chest, abdomen, and pelvis is not recommended (GradeC). Imaging test is recommended in case of an increased serum concentration of HE4 or CA125 (Grade B). An HRT should be proposed to women younger than 45 after a non-conservative treatment for a high grade serous (GradeC) or for a mucinous (GradeC) ovarian, tubal or primitive peritoneal adenocarcinoma. HRT is not contra-indicated in women older than 45 presenting a climacteric syndrome after the treatment of a high grade serous (Grade B) or of a mucinous (GradeC) ovarian, tubal or primitive peritoneal adenocarcinoma.

Saliva CA125 and TPS Levels in Patients with Oral Squamous Cell Carcinoma

Objectives

To determine the levels of carbohydrate antigen 125 (CA125) and tissue polypeptide-specific antigen (TPS) in saliva of patients with oral squamous cell carcinoma (OSCC) and patients with nonneoplastic disease of the oral cavity, and to investigate their diagnostic value and their relationship with pathological grade and clinical stage.

Methods

A total of 97 hospitalized patients with OSCC, 36 patients with nonneoplastic disease of the oral cavity and 50 healthy individuals were included in this investigation. Mixed saliva was collected from these patients and the healthy controls before treatment. Saliva samples were analyzed by enzyme-linked immunosorbent assay (ELISA).

Results

The saliva CA125 and TPS concentrations were significantly higher in patients with OSCC than in patients with nonneoplastic disease and healthy controls, but not significantly different between patients with nonneoplastic disease and controls. Neither the saliva CA125 nor the TPS level was correlated with pathological grade and clinical stage. The sensitivity, specificity and accuracy of saliva CA125 and TPS for the diagnosis of OSCC were 80.0%, 66.0%, 75.7%, and 82.1%, 74.0%, 79.3%, respectively. When CA125 and TPS were analyzed independently, there was no significant difference in sensitivity, specificity and accuracy between the two markers. When CA125 and TPS were analyzed in combination, there was no significant difference in sensitivity, specificity and accuracy between independent detection and combined detection.

Conclusions

The saliva CA125 and TPS concentrations were elevated in patients with OSCC. CA125 and TPS may prove to be useful tumor markers in OSCC.

Follow-up of patients who are clinically disease-free after primary treatment for fallopian tube, primary peritoneal, or epithelial ovarian cancer: a Program in Evidence-Based Care guideline adaptation

BACKGROUND

A need for follow-up recommendations for survivors of fallopian tube, primary peritoneal, or epithelial ovarian cancer after completion of primary treatment was identified by Cancer Care Ontario's Program in Evidence-Based Care.

METHODS

We searched for existing guidelines, conducted a systematic review (medline, embase, and cdsr, January 2010 to March 2015), created draft recommendations, and completed a comprehensive review process. Outcomes included overall survival, quality of life, and patient preferences.

RESULTS

The Cancer Australia guidance document Follow Up of Women with Epithelial Ovarian Cancer was adapted for the Ontario context. A key randomized controlled trial found that the overall survival rate did not differ between asymptomatic women who received early treatment based on elevated serum cancer antigen 125 (ca125) alone and women who waited for the appearance of clinical symptoms before initiating treatment (hazard ratio: 0.98; 95% confidence interval: 0.80 to 1.20; p = 0.85); in addition, patients in the delayed treatment group reported good global health scores for longer. No randomized studies were found for other types of follow-up. We recommend that survivors be made aware of the potential harms and benefits of surveillance, including a discussion of the limitations of ca125 testing. Women could be offered the option of no formal follow-up or a follow-up schedule that is agreed upon by the woman and her health care provider. Education about the most common symptoms of recurrence should be provided. Alternative models of care such as nurse-led or telephone-based follow-up (or both) could be emerging options.

CONCLUSIONS

The recommendations provided in this guidance document have a limited evidence base. Recommendations should be updated as further information becomes available.

Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

Ovarian cancer is the sixth most common cancer and seventh commonest cause of death in women worldwide. Traditionally, many people who have been treated for cancer undergo long-term follow-up in secondary care. However, it has been suggested that the use of routine review may not be effective in improving survival, quality of life (QoL), or relieving anxiety, or both. In addition, traditional follow-up may not be cost-effective.

OBJECTIVES

To compare the potential benefits of different strategies of follow-up in patients with epithelial ovarian cancer following completion of primary treatment.

SEARCH METHODS

For this update we searched the Cochrane Gynaecological Cancer Group Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) Issue 7, 2013, MEDLINE and EMBASE from November 2010 to July 2013. We also searched reference lists of review articles and contacted experts in the field.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) that evaluated follow-up strategies for women with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias.

MAIN RESULTS

The authors did not identify any new studies that were eligible for inclusion in this update of the review. The search for the original review identified only one RCT that met the inclusion criteria, which included 529 women. This study reported data on immediate treatment of ovarian cancer relapse following rise of serum CA125 levels versus delaying treatment until symptoms developed. All the women participating had previous confirmation of remission, with normal CA125 concentration and no radiological evidence of disease, after surgery and first-line chemotherapy for ovarian cancer.Overall survival between the immediate and delayed arms showed no difference after a median follow-up of 56.9 months (unadjusted hazard ratio (HR) 0.98, 95% confidence interval (CI) 0.80 to 1.20; P value 0.85). Time from randomisation to first deterioration in global health score or death was shorter in the immediate treatment group than in the delayed treatment group (HR 0.71, 95% CI 0.58 to 0.88; P value < 0.01). The trial was at low risk of bias.

AUTHORS' CONCLUSIONS

Limited evidence from a single trial suggests that routine surveillance with CA125 in asymptomatic patients and treatment at CA125 relapse does not seem to offer survival advantage when compared to treatment at symptomatic relapse. RCTs are needed to compare different types of follow-up, looking at survival, QoL, cost and psychological effects as outcomes.

Serum soluble mesothelin-related peptide (SMRP): a potential diagnostic and monitoring marker for epithelial ovarian cancer

PURPOSE

To explore the potential and diagnostic performance of soluble mesothelin-related peptide (SMRP) as a tumor marker for epithelial ovarian cancer (EOC).

METHODS

Sera were obtained from 78 EOC patients, 84 benign ovarian tumor patients, 58 healthy volunteers, and 22/78 EOC patients 1 week after surgery. SMRP levels and diagnostic performance were assessed by ELISA using the MESOMARK kit. The combination of SMRP and CA125 in the diagnosis of EOC was assessed.

RESULTS

SMRP concentrations were higher in EOC patients than in benign tumor patients and healthy volunteers, and SMRP levels were shown to decrease in EOC patients after surgery. Histological EOC subtypes showed significant differences in SMRP levels. Stage III-IV patients had a higher level of SMRP than stage I-II patients (P < 0.001). Elevated SMRP levels were also found in higher grade tumors (P < 0.001). The receiver operating characteristic curve for SMRP was 0.891. The best statistical cut-off for SMRP was 1.3109 nM, with 0.821 sensitivity and 0.979 specificity. When compared with CA125, SMRP performed better in specificity, omission diagnostic rate, positive predictive value, and correction rate, but worse for sensitivity and negative predictive value. The combination of SMRP and CA125 gave a sensitivity of 98.4 % and a specificity of 88.9 %.

CONCLUSION

Serum SMRP is a promising marker for the diagnosis and monitoring of EOC, especially in combination with CA125.

Biomarkers, the molecular gaze and the transformation of cancer survivorship

Over the past two decades, molecular technologies have transformed the landscape of cancer diagnosis, treatment and disease surveillance. However, although the effects of these technologies in the areas of primary and secondary cancer prevention have been the focus of growing study, their role in tertiary prevention remains largely unexamined. Treating this topic as a problematic to be conceptually explored rather than empirically demonstrated, this article focuses on the molecularisation of tertiary prevention, especially the growing use of molecular biomarkers to monitor disease recurrence. Taking a semiotic approach, I speculate on the potential meanings of molecular biomarkers for people living with and beyond cancer and suggest the meanings of these technologies may differ in important ways for those on both sides of the risk divide: that is, those 'at risk' for cancer and those living with realised risk. Although molecular biomarkers may intensify a sense of 'measured vulnerability', by indexing cancer's presence they may also prove reassuring. Moreover, as an invisible but ostensibly 'transparent' sign, in some contexts they appear to enable cancer survivors to challenge biomedical decision making. In the light of recent oncological debates about the value of these biomarkers in tertiary prevention, I conclude by suggesting that signs can never be reduced to their 'objective' biomedical denotation in spite of professional attempts to expunge meaning and value from care.

Evaluation of follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment

BACKGROUND

Ovarian cancer is the sixth most common cancer and seventh cause of cancer death in women worldwide. Traditionally, many patients who have been treated for cancer undergo long-term follow up in secondary care. Recently however it has been suggested that the use of routine review may not be effective in improving survival, quality of life (QoL), and relieving anxiety. In addition, it may not be cost effective.

OBJECTIVES

To compare the potential benefits of different strategies of follow up in women with epithelial ovarian cancer following completion of primary treatment.

SEARCH STRATEGY

We searched the Cochrane Gynaecological Cancer Group Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library, 2010, Issue 4), MEDLINE and EMBASE (to November 2010). We also searched CINAHL, PsycLIT, registers of clinical trials, abstracts of scientific meetings, reference lists of review articles, and contacted experts in the field.

SELECTION CRITERIA

All relevant randomised controlled trials (RCTs) that evaluated follow-up strategies for patients with epithelial ovarian cancer following completion of primary treatment.

DATA COLLECTION AND ANALYSIS

Two review authors independently abstracted data and assessed risk of bias.

MAIN RESULTS

We found only one RCT (Rustin 2010) that met our inclusion criteria. This trial included 529 women and reported data on immediate treatment versus delayed treatment in women with confirmation of remission and with normal CA125 concentration and no radiological evidence of disease after surgery and first-line chemotherapy.Overall survival showed no significant difference between the immediate and delayed arms after a median follow up of 56.9 months (unadjusted hazard ratio (HR) = 0·98, 95% confidence interval (CI) 0·80 to 1·20; P = 0·85). Time from randomisation to first deterioration in global health score or death was significantly shorter in the early group compared with the delayed group (HR 0·71, 95% CI 0·58 to 0·88; P < 0·01). The trial was at low risk of bias.

AUTHORS' CONCLUSIONS

There is a lack of randomised studies on most aspects of follow-up care after treatment for epithelial ovarian cancers. Limited evidence from a single trial suggests that routine surveillance with CA125 in asymptomatic patients, with treatment at CA125 relapse, does not seem to offer survival advantage when compared to treatment at symptomatic relapse. Randomised controlled trials are needed to compare different types of follow up on the outcomes of survival, quality of Life, cost and psychological effects.

Cancergazing? CA125 and post-treatment surveillance in advanced ovarian cancer

Post-treatment surveillance of advanced ovarian cancer involves regular testing of asymptomatic patients using the CA125 test. This practice is based on a rationale that is not supported by evidence from clinical trials. This paper aims to stimulate critical reflection concerning the effect of investigative tests on clinical decisions and interactions, and the experience of illness, particularly in the context of advanced malignant disease. Drawing on the idea of the "medical gaze", and building on previous health communication research, we present an analysis of in-depth interviews and psychometric tests collected in a prospective study of 20 Australian women with advanced ovarian cancer conducted between 2006 and 2009. We describe the demands placed on patients by the use of the CA125 test, some hazards it creates for decision-making, and some of the test's subjective benefits. It is widely believed that the CA125 test generates anxiety among patients, and the proposed solution is to educate women more about the test. We found no evidence that anxiety was a problem requiring a response over and above existing services. We conclude that the current debate is simplistic and limited. Focussing on patient anxiety does not account for other important effects of post-treatment surveillance, and educating patients about the test is unlikely to mitigate anxiety because testing is part of a wider process by which patients become aware of a disease that--once it has relapsed--will certainly kill them in the near future.