Towards evidence-based use of serum tumour marker requests: an audit of use in a tertiary hospital

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.

Inappropriate practice in tumor marker requests at a university hospital in Western Saudi Arabia: A 3-year retrospective study

OBJECTIVES

This study assessed the level of appropriateness of tumor marker requests in a teaching hospital and estimated the financial cost associated with inappropriate use.

METHODS

A retrospective review of patients' electronic records was conducted over a 3-year period (2015-2017) for tumor marker requests, including carcinoembryonic antigen, alpha-fetoprotein, cancer antigen (CA)15-3, CA125, CA19-9, and total and free prostate-specific antigen (PSA and fPSA), along with the associated clinical data that motivated the requests. Inappropriate use was defined as tumor marker requests without any relevant clinical picture. Costs due to inappropriate tumor marker requests were estimated based on the unit costs applied in the institution.

RESULTS

A total of 7128 patients had at least one tumor marker request between 2015 and 2017. The clinical picture that motivated tumor marker requests was absent in 71.5%, while 12.9% of the requests were associated with a malignancy. The most frequent prescribing pattern was total prostate-specific antigen alone (2128; 29.9%), followed by alpha-fetoprotein alone (1185; 16.6%), and carcinoembryonic antigen alone (506; 7.1%). Year-over-year analysis revealed an increasing tendency in requesting carcinoembryonic antigen and CA15-3. The rate of inappropriate use varied by tumor marker and ranged between 56.4% for fPSA and 86.8% for total prostate-specific antigen. The overall costs due to inappropriate tumor marker requests were estimated at $2,785,493 over the 3 years, representing an average of $0.93 million per year.

CONCLUSION

Inappropriate use of tumor marker requests is a major issue regarding its high prevalence and the considerable associated costs. The role of laboratories in the management of tumor marker requests should be emphasized.

Indicators of inappropriate tumour marker use through the mining of electronic health records

RATIONALE, AIMS, AND OBJECTIVES

Although the issue of monitoring appropriateness of tumour markers (TMs) request in outpatients remains crucial, proper indicators are still demanding. The present study developed and explored indicators of inappropriate TM ordering in outpatients through the data mining of electronic health records (EHRs).

METHODS

Carcinoembryonic antigen (CEA), alfa-fetoprotein (AFP), carbohydrate antigen (CA)125, CA15.3, CA19.9, and prostate-specific antigen (PSA) ordered in outpatients during a year were examined by mining EHRs of a Local Health Authority in Italy. Evidence-based criteria were used to develop performance indicators. Demographic and clinical information associated with TM orders were examined.

RESULTS

A total of 80 813 TMs were ordered in 52 536 outpatients (1.54 markers/patient). Indicators related to disease codes, gender, age, and TM repetitions were developed, and their application showed that (1) CA15.3 and CEA are prevalently requested in patients with cancer (79.2% and 65.6%) whereas the other TMs are largely requested also in patients without cancer; (2) requests of PSA in women and of CA125 or CA15.3 in men are negligible; (3) although requests in people older than 80 years are relevant (16.4% of total), the highest rate of request of all markers occurs in patients aged 40 to 79 years; (4) CA15.3 and CEA are mainly requested in cancer cases between 50 and 79 years and AFP, CA19.9, and CA125 in those between 60 and 69 years; (5) <50% of PSA orders are associated with cancer code for all age intervals; and (6) multiple repetitions of AFP, CA125, CA15.3, CA19.9, and CEA are prevalent in cancer patients or benign diseases to which TMs are appropriate, whereas PSA repetitions occur mainly in patients without cancer.

CONCLUSIONS

The developed indicators resulted suitable to monitor TM overordering in outpatients through the mining of EHRs. The present study is a first approach towards the use of big-data mining for TM appropriateness evaluation purposes.

Tumor Marker Ordering: Do Not Lose Control: A Prospective Clinical Trial

OBJECTIVES

In this study, we evaluated the extent of inappropriate tumor marker (TM) ordering in a secondary care setting, approximately 6 years after the introduction of local guidelines, and we identified the main factors potentially influencing clinicians when performing an inappropriate TM request.

METHODS

For this purpose, we regularly checked all requests containing more than two TMs. During the 21-month audit, the rate of rejected requests amounted to 3.6%. Several of those were performed for diagnostic purposes. The most frequent and inappropriately requested TMs were carcinoembryonic antigen and carbohydrate antigen 19.9.

RESULTS

The inappropriateness of requests appeared to be linked to the need for more education and knowledge on their clinical applicability and limitations. The clinical motivation was generally associated with patients displaying nonspecific signs/symptoms (ie, weight loss with worsening general conditions), having an incidentally positive result to some recently performed TM tests, or being tested by a TM to avoid more expensive diagnostic imaging procedures.

CONCLUSIONS

Our data show that real-time control and management of inappropriate requests by laboratory professionals may be relevant to increase the clinical efficacy of TM testing and useful in perspective to drive the introduction of new validated biomarkers.

Injudicious use of laboratory facilities in tertiary care hospitals at Rawalpindi, Pakistan: a cross-sectional descriptive study

Background

In recent years inappropriate and excessive use of clinical laboratory facilities has become a cause of concern and has led to concurrent rise in the laboratory errors and the health care costs. The aim of the study was to find out the frequency of incomplete laboratory request forms, inappropriate test requests at various professional levels and the financial impact of uncollected reports at Armed Forces Institute of Pathology (AFIP) and Combined Military Hospital (CMH) Laboratory Rawalpindi.

Methods

The cross-sectional descriptive study was conducted during a three month period from April to June 2012 at AFIP and CMH Laboratory Rawalpindi. A total of 1000 laboratory request forms were collected and scrutinized for completion from AFIP (n=500) and CMH Rawalpindi laboratory (n=500). 536 request forms of costly/specialized tests from different departments of AFIP were studied to find out the professional level of test request. The total number of tests performed at AFIP during the study period and number of uncollected reports were noted. The financial impact of these uncollected reports was also calculated. Collection of data and sorting were done manually. Patient confidentiality was maintained. Microsoft excel software and SPSS-17 were used for analysis. The study was approved by the Institutional Ethical Review Committee.

Results

Out of a total of 1000 forms studied none was completely filled with clinical notes being present in only 2.4% and 13% of forms sent to CMH and AFIP respectively. 62% of the expensive investigations were requested by specialists while 38% were ordered by residents and general practitioners but the percentage of avoidable expensive tests ordered by the general practitioners and residents was significantly higher than the specialists(p<0.001). A total of 9026 (40%) and 5046 (22%) diagnostic test reports were not collected from the Chemical pathology and Hematology departments respectively. Financial impact of uncollected reports from all the departments at AFIP collectively amounted to Pakistani Rupees (PKR) 3338201.

Conclusion

Processing incomplete laboratory request forms and injudicious use of laboratory facilities leads to incorrect interpretation of laboratory test results affecting outcome of the overall treatment.

The landscape of inappropriate laboratory testing: a 15-year meta-analysis

BACKGROUND

Laboratory testing is the single highest-volume medical activity and drives clinical decision-making across medicine. However, the overall landscape of inappropriate testing, which is thought to be dominated by repeat testing, is unclear. Systematic differences in initial vs. repeat testing, measurement criteria, and other factors would suggest new priorities for improving laboratory testing.

METHODS

A multi-database systematic review was performed on published studies from 1997-2012 using strict inclusion and exclusion criteria. Over- vs. underutilization, initial vs. repeat testing, low- vs. high-volume testing, subjective vs. objective appropriateness criteria, and restrictive vs. permissive appropriateness criteria, among other factors, were assessed.

RESULTS

Overall mean rates of over- and underutilization were 20.6% (95% CI 16.2-24.9%) and 44.8% (95% CI 33.8-55.8%). Overutilization during initial testing (43.9%; 95% CI 35.4-52.5%) was six times higher than during repeat testing (7.4%; 95% CI 2.5-12.3%; P for stratum difference <0.001). Overutilization of low-volume tests (32.2%; 95% CI 25.0-39.4%) was three times that of high-volume tests (10.2%; 95% CI 2.6-17.7%; P<0.001). Overutilization measured according to restrictive criteria (44.2%; 95% CI 36.8-51.6%) was three times higher than for permissive criteria (12.0%; 95% CI 8.0-16.0%; P<0.001). Overutilization measured using subjective criteria (29.0%; 95% CI 21.9-36.1%) was nearly twice as high as for objective criteria (16.1%; 95% CI 11.0-21.2%; P = 0.004). Together, these factors explained over half (54%) of the overall variability in overutilization. There were no statistically significant differences between studies from the United States vs. elsewhere (P = 0.38) or among chemistry, hematology, microbiology, and molecular tests (P = 0.05-0.65) and no robust statistically significant trends over time.

CONCLUSIONS

The landscape of overutilization varies systematically by clinical setting (initial vs. repeat), test volume, and measurement criteria. Underutilization is also widespread, but understudied. Expanding the current focus on reducing repeat testing to include ordering the right test during initial evaluation may lead to fewer errors and better care.

The impact of local guidelines on the tumour marker requesting patterns of a General Surgery Department

Background

The inappropriate use of tumour markers (TMs) is a common problem. The aim of this audit was to evaluate the impact of local guidelines on the TM requesting patterns of a General Surgery Department.

Methods

CA 125, CA 19-9, CA15-3, CEA, AFP and HCG requests from all hospital surgical locations were audited over two periods of eight months before and after the implementation of local requesting guidelines.

Results

Postintervention, total TM requests decreased by 32% while patient requests decreased by 9.8%. Single TM requesting increased and requests for panels containing four or more TMs decreased from 279 to 60 requests (78% reduction).

Conclusion

Interdepartmental collaboration and the implementation of local guidelines have resulted in a change in requesting behaviour, most notably a reduction in multiple TM panel requests.

Elevated tumour marker: an indication for imaging?

INTRODUCTION

The purpose of this study was to evaluate the utility of imaging examinations in patients with elevated tumour markers when (a) the tumour marker is not validated for as a primary diagnostic test; (b) the patient had no personal history of cancer and (c) the patient had no other imaging indication.

MATERIALS AND METHODS

Patients without known cancer who had abnormal carcinoembryonic antigen, CA19-9, CA125 and/or CA15-3 serology over a one-year period were included. A retrospective medical record review was performed to assess the number of these cases who underwent imaging because of 'elevated tumour marker' in the absence of a clinical indication for imaging. The number and result of these imaging studies were evaluated.

RESULTS

Eight hundred and nineteen patients were included. Of those, 25 patients (mean age: 67.8 [range 41-91] y), were imaged to evaluate: 'elevated tumour marker'. They underwent 29 imaging studies (mean [+/-standard deviation (SD)] per patient = 1.2 [+/-0.4]), and had 42 elevated tumour marker serology tests (mean [+/-SD] per patient = 1.7 [+/-0.7]). Four patients had >1 imaging test. No patient had an imaging study which diagnosed a malignancy or explained the elevated tumour marker.

CONCLUSION

The non-judicious use of tumour markers can prompt further unnecessary investigations including imaging. In this study, there was no positive diagnostic yield for imaging performed for investigation of 'elevated tumour marker'. 'Elevated tumour marker', in the absence of a known underlying malignancy, should not be considered an independent indication for imaging.

Tumour markers requesting pattern with regards to different organizational settings in Italy: a survey of hospital laboratories

Background

Tumour markers are frequently used in clinical practice and the reason for ordering varies considerably and often seems to be inappropriate. We carried out a survey of Italian laboratories on their current pattern of use.

Methods

Forty-four laboratories located in health-care institutions with inpatient beds were surveyed about the organizational, clinical and methodological aspects of tumour markers ordering.

Results

Thirty-one laboratories (70%) filled in and returned the questionnaire. Overall, 977,786 tumour marker tests were scrutinized. The pattern of tumour marker use did not seem to be influenced by the institutional setting, by availability of oncology facilities or by adoption of clinical guidelines. In addition, the information flow from clinicians to the laboratory and vice versa was poor and informal.

Conclusions

Monitoring tumour marker pattern use can provide valuable information for health-care decision makers, highlighting potential inadequacies in laboratory services but also identifying problems in other areas of health-care delivery that could benefit from educational programmes.

An audit of tumour marker utilization in Greece

INTRODUCTION

Several international organizations have published guidelines for the correct use of tumour markers in clinical practice. However, there are reports that clinicians do not adhere to these guidelines in clinical practice. The present study constitutes an audit of TM use in a major hospital in Northern Greece. Purpose of our study is to quantify the magnitude of inappropriate TM requests as well as the corresponding financial cost.

METHODS

We examined retrospectively all TM requests between 10/2006 and 07/2007 in the department of biochemistry of our hospital. The tumour markers included in our study were: CA 19-9, CA 125, CA 15-3, AFP, NSE, CYFRA 21-1 and CEA.

RESULTS

We found 9782 inappropriate TM orders. For five of them - namely CA 125, AFP, CA 19-9, CYFRA 21-1 and NSE - the proper requests were below 10%. There were 5.6 TM requests per patient. The total cost for inappropriate TM reached 239,748 euro, which corresponds to a monthly cost of 23,974euro.

CONCLUSIONS

There is considerable inappropriateness in the utilization of TM in Greece which corresponds to significant financial cost. Various measures should be applied in order to increase the cost-effectiveness of TM use.

Markedly elevated CA19-9 associated with benign ovarian cyst and ascites

A 60-year-old woman presented after a fall and was noted to have ascites. She had a history of ulcerative colitis. History and physical examination did not reveal the likely aetiology of the ascites, but a sample showed it to be a blood-stained exudate. A malignant cause appeared likely, cross-sectional imaging was arranged and tumour markers sent. CA125 was 34 IU/ml (0-30); α-fetoprotein (AFP) and carcinoembryonic antigen (CEA) were normal. However, CA19-9 was 2880 U/ml (0-31). Pancreatic carcinoma or cholangiocarcinoma were of prime concern, but a CT scan and MRI imaging were normal. At laparoscopy a benign ruptured ovarian cyst was detected, and ascites drained. CA19-9 returned to normal and the patient remains well 9 months later. This case demonstrates how tumour markers may be misleading in the context of diagnostics, and is the highest reported example of CA19-9 rise in the context of benign ascites and benign ovarian pathology.

National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for use of tumor markers in clinical practice: quality requirements

BACKGROUND

This report presents updated National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines summarizing quality requirements for the use of tumor markers.

METHODS

One subcommittee developed guidelines for analytical quality relevant to serum and tissue-based tumor markers in current clinical practice. Two other subcommittees formulated recommendations particularly relevant to the developing technologies of microarrays and mass spectrometry.

RESULTS

Prerequisites for optimal use of tumor markers in routine practice include formulation of the correct clinical questions to ensure selection of the appropriate test, adherence to good clinical and laboratory practices (e.g., minimization of the risk of incorrect patient and/or specimen identification, tube type, or timing), use of internationally standardized and well-characterized methods, careful adherence to manufacturer instructions, and proactive and timely reactions to information derived from both internal QC and proficiency-testing specimens. Highly desirable procedures include those designed to minimize the risk of the reporting of erroneous results attributable to interferences such as heterophilic antibodies or hook effects, to facilitate the provision of informative clinical reports (e.g., cumulative and/or graphical reports, appropriately derived reference intervals, and interpretative comments), and when possible to integrate these reports with other patient information through electronic health records. Also mandatory is extensive validation encompassing all stages of analysis before introduction of new technologies such as microarrays and mass spectrometry. Provision of high-quality tumor marker services is facilitated by dialogue involving researchers, diagnostic companies, clinical and laboratory users, and regulatory agencies.

CONCLUSIONS

Implementation of these recommendations, adapted to local practice, should encourage optimization of the clinical use of tumor markers.

Mass Spectrometry: Uncovering the Cancer Proteome for Diagnostics

Despite impressive scientific achievements over the past few decades, cancer is still a leading cause of death. One of the major reasons is that most cancer patients are diagnosed with advanced disease. This is clearly illustrated with ovarian cancer in which the overall 5-year survival rates are only 20-30%. Conversely, when ovarian cancer is detected early (stage 1), the 5-year survival rate increases to 95%. Biomarkers, as tools for preclinical detection of cancer, have the potential to revolutionize the field of clinical diagnostics. The emerging field of clinical proteomics has found applications across a wide spectrum of cancer research. This chapter will focus on mass spectrometry as a proteomic technology implemented in three areas of cancer: diagnostics, tissue imaging, and biomarker discovery. Despite its power, it is also important to realize the preanalytical, analytical, and postanalytical limitations currently associated with this methodology. The ultimate endpoint of clinical proteomics is individualized therapy. It is essential that research groups, the industry, and physicians collaborate to conduct large prospective, multicenter clinical trials to validate and standardize this technology, for it to have real clinical impact.