Appropriateness of tumor marker request: a case of study

Evaluating potential overuse of surveillance care in cancer survivors

BACKGROUND

Survivorship care plans (SCPs) communicate cancer-related information from oncology providers to patients and primary care providers. SCPs may limit overuse testing by specifying necessary follow-up care. From a randomized, controlled trial of SCP delivery, we examined whether cancer-related tests not specified in SCPs, but conducted after SCP receipt, were appropriate or consistent with overuse.

METHODS

Survivors of breast, colorectal, or prostate cancer treated at urban-academic or rural-community health systems were randomized to one of three SCP delivery arms. Tests during 18 months after SCP receipt were classified as consistent with overuse if they were (1) not included in SCPs and (2) on a guideline-based predetermined list of "not recommended surveillance." After chart abstraction, physicians performed review and adjudication of potential overuse. Descriptive analyses were conducted of tests consistent with overuse. Negative binomial regression models determined if testing consistent with overuse differed across study arms.

RESULTS

Among 316 patients (137 breast, 67 colorectal, 112 prostate), 140 individual tests were identified as potential overuse. Upon review, 98 were deemed to be consistent with overuse: 78 tumor markers and 20 imaging tests. The majority of overuse testing was breast cancer-related (95%). Across sites, 27 patients (9%) received ≥1 test consistent with overuse; most were breast cancer patients (22/27). Exploratory analyses of overuse test frequency by study arm showed no significant difference.

CONCLUSIONS

This analysis identified practice patterns consistent with overuse of surveillance testing and can inform efforts to improve guideline-concordant care. Future interventions may include individual practice patterns and provider education.

Consensus of the Spanish society of laboratory medicine and the Spanish society of medical oncology on the methodology and criteria for evaluation of circulating tumour markers in breast cancer

The measurement of circulating tumour markers (TMs) for the diagnosis or monitoring of breast cancer has sometimes been considered of limited utility. In addition to the overinterpretation of irrelevant changes in marker levels, the characteristics of the patient, the disease or other pathologies that can modify them are often not considered in their evaluation. On the other hand, there are recent data on the relationship of TMs with molecular subtypes and on their prognostic value, the knowledge of which may improve their clinical utility. This consensus article arises from a collaboration between the Spanish Society of Laboratory Medicine (SEQC^ML) and the Spanish Society of Medical Oncology (SEOM). It aims to improve the use and interpretation of circulating TMs in breast cancer. The text summarizes the current knowledge and available evidence on the subject and proposes a series of recommendations mainly focussed on the indication, the frequency of testing and the factors that should be considered for correctly interpreting changes in the levels of TMs.

Serum Tumor Markers in Paraneoplastic Neurologic Syndromes: A Systematic Review of Guidelines

Purpose: Algorithms for the detection of a malignancy in patients with unclear neurologic symptoms of suspicious paraneoplastic origins are not universally applied. Frequently, circulating tumor markers (TMs) are considered a valuable tool for cancer diagnosis in patients with paraneoplastic neurologic syndromes (PNS). Our aim was to extract the recommendations on the use of TMs and onconeural antibodies (Abs) for the diagnosis of malignancies in PNS from clinical practice guidelines and put them forward as evidence in a common framework to facilitate diffusion, dissemination, and implementation.

Methods: Systematic literature searches were performed for guidelines on both oncology and PNS published since 2007. Guidelines containing information and recommendations for clinical practice pertaining to the screening and diagnosis of PNS were selected. Information on circulating TMs and onconeural Abs was extracted and synthesized in consecutive steps of increasing simplification.

Results: We retrieved 799 eligible guidelines on oncology for the potential presence of information on PNS but only six covered treated diagnosis or the screening of cancer in PNS, which were then selected. Seventy-nine potentially relevant guidelines on PNS were identified as eligible and 15 were selected. Synoptic tables were prepared showing that classical TMs are not recommended for the screening or the diagnosis of a malignancy in patients with a suspected PNS. Neither should onconeural Abs be considered to screen for the presence of a malignancy, although they could be helpful to define the probability of the paraneoplastic origin of a neurologic disorder.

Conclusion: The present work of synthesis may be a useful tool in the diffusion, dissemination, and implementation of guideline recommendations, potentially facilitating the decrease of the inappropriate use of circulating biomarkers for cancer screening in the presence of PNS.

Appropriateness of Using Tests for Blood Glucose and Diabetic Complications in Clinical Practice: Experiences in a Hospital in Thailand

BACKGROUND This study aimed to evaluate how the tests for blood glucose (BG) and diabetic complications have been utilized in a hospital in Thailand. MATERIAL AND METHODS Patient medical records having the results of BG, HbA1c, and/or urine microalbumin presented and the records of DM patients having the results of serum lipids, serum LDL-C, and/or serum creatinine presented were selected. The data of diagnosis, ordered tests, and testing results in these records were extracted for evaluation. RESULTS This study recruited 1066 patients diagnosed with DM and 3081 patients diagnosed with other diseases. Point-of-care testing (POCT) for BG was repeatedly used in 371 non-DM cases; most of its results were normal. The results of BG and HbA1c were often used together. There was a good relationship between them, and these test results indicated poor glycemic control in 58% of DM cases. In non-DM cases, the test results agreed, indicating normoglycemia in 17.32%, pre-diabetes in 20.47%, and diabetes in 21.78%. To prevent diabetic nephropathy, serum creatinine was frequently used, whereas urine microalbumin, the recommended test, was underutilized. The result of LDL-C from both direct measurement and calculation were used; however, based on the same guidelines, the results of measured LDL-C indicated risk of cardiovascular diseases in a higher percentage of DM cases than did the results of calculated LDL-C. CONCLUSIONS The use of POCT for BG in hospitalized patients may be inappropriate. The utilization of urine microalbumin should be promoted to effectively prevent diabetic nephropathy.