open access: CLINICIAN'S CORNER - Management of Ovarian Cancer, April 4, 2012 — JAMA (clear cell/endometrioid)

Management of Ovarian Cancer, April 4, 2012, — JAMA

"Using the case of Ms W, we discuss the signs, symptoms, risk factors, and prognostic factors of epithelial ovarian cancer; review the evidence for surgical and postoperative medical management; and present the current recommendations for screening and follow-up......

"A 75-Year-Old Woman Who Has Completed Treatment".......

March 22, 2012: Journal of Ovarian Research | open access | The value of serum CA125 for the development of virtual follow-up strategies for patients with epithelial ovarian cancer: A retrospective study

Blogger's Note: past studies also confirm the connection between doubling of CA125/nadir, focus on remote care/followup

Journal of Ovarian Research | Abstract | The value of serum CA125 for the development of virtual follow-up strategies for patients with epithelial ovarian cancer: A retrospective study

Research

"Current NCCN guidelines for the follow up of patients with EOC are widely accepted but only limited evidence is available to support current clinical practice [3]. There are no clinical trials available to determine optimal follow up intervals, sequence or duration of follow up."

The value of serum CA125 for the development of virtual follow-up strategies for patients with epithelial ovarian cancer: A retrospective study

Journal of Ovarian Research 2012, 5:11 doi:10.1186/1757-2215-5-11
Published: 22 March 2012

Abstract (provisional)

Background

Serum CA125 is routinely used in the follow up of ovarian cancer. The objective of the present study was to evaluate the usefulness of CA125 in the detection of ovarian cancer recurrence.

Methods

This retrospective case study was carried out at a tertiary gynaecological cancer centre in Australia. Patients with all cell types of epithelial ovarian cancer (EOC) treated between 2003 and 2010 were considered eligible. We excluded patients whose aim of treatment was palliative, had no follow-up, had no pre-operative CA125 reading or had pre-operative CA125 levels < 35 U/mL. After primary treatment, patients were followed up as per guidelines suggested by National Comprehensive Cancer Network (NCCN). We recorded if symptoms, findings from physical examination, imaging or serum CA125 levels led to the diagnosis of recurrence. An increase in CA125 levels to twice the postoperative nadir was considered as "doubling" at any time during follow up.

Results

Analysis is based on 56 patients who completed primary treatment and who presented for a total of 274 follow-up episodes. Of those, 29 patients (52%) developed a recurrence within the follow up period. Recurrence was diagnosed by CA125 alone in 14 of 29 patients (48%). CA125 was not elevated in 7 patients (24%) who recurred. Doubling of CA125 from nadir was observed in 27/29 patients. Of those 27 patients the doubling from nadir occurred within the normal range of 35 U/ml in 3 cases and outside the normal range in 24 cases. Multivariate analysis suggests that doubling of serum CA125 (OR 5.10, p 0.036) and nadir CA125 >10 U/ml (OR 2.86, p 0.01) remained the only independent factors to predict ovarian cancer recurrence.

Conclusions

The present paper proposes the validation of a novel CA125 algorithm aiming to detect recurrent EOC. These data may allow us to investigate novel ways of follow up that do not require a patient's physical attendance at a clinic (virtual follow-up).

The complete article is available as a provisional PDF. The fully formatted PDF and HTML versions are in production.

abstract: Presence of key findings in the medical record prior to a documented high-risk diagnosis.

Presence of key findings in the medical record prior to a documented high-risk diagnosis.


Abstract

Background
Failure or delay in diagnosis is a common preventable source of error. The authors sought to determine the frequency with which high-information clinical findings (HIFs) suggestive of a high-risk diagnosis (HRD) appear in the medical record before HRD documentation.
  
Methods
A knowledge base from a diagnostic decision support system was used to identify HIFs for selected HRDs: lumbar disc disease, myocardial infarction, appendicitis, and colon, breast, lung, ovarian and bladder carcinomas. Two physicians reviewed at least 20 patient records retrieved from a research patient data registry for each of these eight HRDs and for age- and gender-compatible controls. Records were searched for HIFs in visit notes that were created before the HRD was established in the electronic record and in general medical visit notes for controls.

Results
25% of records reviewed (61/243) contained HIFs in notes before the HRD was established. The mean duration between HIFs first occurring in the record and time of diagnosis ranged from 19 days for breast cancer to 2 years for bladder cancer. In three of the eight HRDs, HIFs were much less likely in control patients without the HRD.
  
Conclusions
In many records of patients with an HRD, HIFs were present before the HRD was established. Reasons for delay include non-compliance with recommended follow-up, unusual presentation of a disease, and system errors (eg, lack of laboratory follow-up). The presence of HIFs in clinical records suggests a potential role for the integration of diagnostic decision support into the clinical workflow to provide reminder alerts to improve the diagnostic focus.

open access: CA-125: To Monitor or Not to Monitor?: Evidence Against Monitoring CA-125 For Ovarian Cancer Patients in Remission (Dr's Rustin, Karlan, Markman)

CA-125: To Monitor or Not to Monitor?: Evidence Against Monitoring CA-125

 For Ovarian Cancer Patients in Remission

Gordon Rustin, MD; Beth Y. Karlan, MD; Maurie Markman, MD

Authors and Disclosures

Posted: 03/08/2012

Editor's Note:
 
CA-125 is the most useful tumor marker in ovarian cancer. Since 1981, measurement of the serum level of the CA-125 antigen has become a standard component of routine management of women with advanced ovarian cancer.^[1,2] CA-125 concentrations are used to monitor response to chemotherapy, relapse, and disease progression in ovarian cancer patients. However, the question remains as to whether routine monitoring of CA-125 in women with advanced ovarian cancer in complete remission is advantageous. Recently, Drs. Gordon Rustin and Beth Karlan -- experts in the treatment of ovarian cancer -- participated in a Medscape Virtual Debate via email addressing the question, "Should patients with advanced ovarian cancer in complete remission undergo routine CA-125 monitoring?" Dr. Maurie Markman served as moderator. What follows is their conversation..........cont'd

British Journal of Cancer - Personalised cancer follow-up: risk stratification, needs assessment or both

Follow-up with CA125 after primary therapy of advanced ovarian cancer has major implications for treatment outcome and trial performances and should not be routinely performed

Follow-up with CA125 after primary therapy of advanced ovarian cancer: in favor of continuing to prescribe CA125 during follow-up

Follow-up with CA125 after primary therapy of adva... [Ann Oncol. 2011] - PubMed - NCBI

CONCLUSIONS:

Women should be advised not to have routine CA125 measurements, providing they are well and have no symptoms suggesting relapse. In asymptomatic patients with a rising CA125 level, chemotherapy can be delayed. Earlier stopping of maintenance therapy just because of rising CA125 might deny patients continuing benefit from that therapy. Use of CA125 to define progression could result in platinum-sensitive patients being falsely classified as platinum resistant.

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

Plain language summary

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

Ovarian cancer is the sixth most common cancer and seventh commonest cause of cancer death in women worldwide. Traditionally, many patients who have been treated for cancer undergo long-term follow up in hospitals. Whilst there may be other benefits from follow up, it has been suggested that the use of routine review may not result in women with this disease living longer given that recurrent ovarian cancer is incurable.

We set out to review the evidence for different types of follow up of women who have completed treatment for the commonest type (epithelial, that is coming from the surface of the ovary) of ovarian cancer. Only one good quality  (blogger's note: Rustin trial) randomised (toss of a coin to choose which group) trial was found which could give any evidence on what to do. This trial suggested no increase in length of life from early treatment with chemotherapy for women with recurrence that was identified by a tumour marker (CA125) blood test compared to waiting to give treatment when women developed symptoms from their cancer.

We conclude that the very limited evidence suggests that there may be no benefit from early detection by the blood test and subsequent early chemotherapy for recurrent ovarian cancer. Also, the women having early chemotherapy treatment of their relapsed cancer may have led to a decreased quality of life for these women compared to the group who were treated when they noticed symptoms.

Randomised controlled trials are needed to compare different types of follow up, looking at quality of life and anxiety outcomes. If new treatments become available for relapsed ovarian cancer, the methods of follow up may need re-assessing to see if earlier intervention improves survival or other outcomes.

Medical News: Group Issues Gyn Cancer Follow-Up Guidance - MedPage Today

For ovarian (epithelial)  cancer, the committee recommended:

• Physical exam and review of symptoms: Every three months for two years, followed by increasing intervals
• Pap test: Not indicated
• CA-125: Optional
• Radiographic imaging: Insufficient data to support routine use
• Suspected recurrence: CT and/or PET, plus CA-125

The recommendations differ for non-epithelial ovarian cancer:

• Physical exam and review of symptoms: Every two to four months for two years, then every six months or annually depending on histology
• Serum tumor markers: Every two to four months for two years, then every six months for sex-cord stromal tumors but no longer indicated for germ-cell tumors
• Radiographic imaging: Generally, not indicated or data lacking to support routine use
• Suspected recurrence: CT and tumor markers

Noting a trend toward transitioning more patients from oncologists to primary care physicians, the committee pointed to evidence that many primary care physicians do not feel comfortable with post-treatment surveillance, particularly during the first two years after treatment. (blogger's note: search blog for past papers on these issues, also the 2 years post treatment is based on old data)


Moreover, a survey of primary care providers showed that respondents believed transition of oncology patients could be improved with individualized patient summaries, guidelines for surveillance, and expedited referral for suspected recurrence, the committee members noted.

"Thus, the provision of up-to-date information and the education of both patients and physicians are mandatory," they wrote.

"Action Points

Point out that this report indicates that there is very little evidence that either routine cytologic procedures or imaging are sufficiently useful to detect ovarian and endometrial cancer recurrence and alter response rates to salvage therapy.

Note that this report suggests that the most effective method to detect recurrences is a taking a thorough history, performing a detailed physical examination, and educating patients about relevant symptoms."

Effect of Occult Metastases on Survival in Node-Negative Breast Cancer — NEJM

Conclusions

Occult metastases were an independent prognostic variable in patients with sentinel nodes that were negative on initial examination; however, the magnitude of the difference in outcome at 5 years was small (1.2 percentage points). These data do not indicate a clinical benefit of additional evaluation, including immunohistochemical analysis, of initially negative sentinel nodes in patients with breast cancer. (Funded by the National Cancer Institute; ClinicalTrials.gov number, NCT00003830.)

abstract: Breast and ovarian cancer screening of non-carriers from BRCA1/|2 mutation-positive families: 2-year follow-up of cohorts from France and Quebec : European Journal of Human Genetics

2010 Who Is Responsible? The Role of Family Physicians in the Provision of Supportive Cancer Care

Note: the issues from the family physicians' perspective

Primary Care Physicians' Views of Routine Follow-Up Care of Cancer Survivors

CO Early Release, published online ahead of print Apr 20 2009
Journal of Clinical Oncology, 10.1200/JCO.2008.20.4883


Primary Care Physicians' Views of Routine Follow-Up Care of Cancer Survivors

M. Elisabeth Del Giudice,* Eva Grunfeld, Bart J. Harvey, Eugenia Piliotis, and Sunil Verma
Department of Family and Community Medicine and Dalla Lana School of Public Health, University of Toronto; Sunnybrook Health Sciences Centre; Ontario Institute of Cancer Research and Cancer Care Ontario, Health Services Research Program; and Divisions of Hematology and Medical Oncology, Department of Medicine, Odette Cancer Centre, Toronto, Ontario, Canada.

* To whom correspondence should be addressed. E-mail: lisa.delgiudice@sunnybrook.ca

Purpose: Routine follow-up of adult cancer survivors is an important clinical and health service issue. Because of a lack of evidence supporting advantages of long-term follow-up care in oncology clinics, there is increasing interest for the locus of this care to be provided by primary care physicians (PCPs). However, current Canadian PCP views on this issue have been largely unknown.

Methods: A mail survey of a random sample of PCPs across Canada, stratified by region and proximity to urban centers, was conducted. Views on routine follow-up of adult cancer survivors and modalities to facilitate PCPs in providing this care were determined.

Results: A total of 330 PCPs responded (adjusted response rate, 51.7%). After completion of active treatment, PCPs were willing to assume exclusive responsibility for routine follow-up care after 2.4 ± 2.3 years had elapsed for prostate cancer, 2.6 ± 2.6 years for colorectal cancer, 2.8 ± 2.5 years for breast cancer, and 3.2 ± 2.7 years for lymphoma. PCPs already providing this care were willing to provide exclusive care sooner. The most useful modalities PCPs felt would assist them in assuming exclusive responsibility for follow-up cancer care were (1) a patient-specific letter from the specialist, (2) printed guidelines, (3) expedited routes of rereferral, and (4) expedited access to investigations for suspected recurrence.

Conclusion: With appropriate information and support in place, PCPs reported being willing to assume exclusive responsibility for the follow-up care of adult cancer survivors. Insights gained from this survey may ultimately help guide strategies in providing optimal care to these patients.