Tumour Marker Use in Primary Care

Written by Craig Webster on .

In the last 5 years requests for tumour marker tests from Primary Care have more than doubled. This high use in Primary Care is worrying because the majority of tumour markers (eg. CEA, CA19-9) are neither specific nor sensitive enough for use in the diagnosis of malignancy. See this link for a summary of the main tumour markers, their uses and limitations.

The main use for tumour markers is in monitoring disease progression, treatment or recurrence of a histologically diagnosed cancer. A recent audit of Primary Care requests for tumour markers found that only 9% of CEA and 4% of CA19-9 were requested for these reasons; the rest being for non-specific symptoms.

In contrast to the above, CA125 and PSA do have use in diagnosis of their related cancers, however it should also be noted that these are still only a diagnostic aid and should be used with caution as both can be raised in a number of other benign conditions (see table). Please click the relevant links below of links to guidelines relating to their use in Primary Care.

CA125 link https://pathways.nice.org.uk/pathways/ovarian-cancer

PSA link https://www.gov.uk/guidance/prostate-cancer-risk-management-programme-overview

For symptoms and referral guidelines of other malignancies see the NICE Suspected Cancer Recognition and Referral guidelines. http://pathways.nice.org.uk/pathways/suspected-cancer-recognition-and-referral

You can also use the search bar or test database on this website to find more specific information on the use of each tumour marker.

Tumour marker

Main application

Other tumour elevations

Other limitations

CEA

Monitoring colorectal adenocarcinomas

Breast, lung, gastric, mesotheliomas, oesophageal and pancreatic

Raised in smokers

Raised in other benign renal, liver, lung or GI disease

Poor sensitivity in early disease and may be absent/low in poorly differentiated tumours

CA19-9

Monitoring pancreatic carcinoma

 

Raised in obstructive jaundice, cholestasis, cirrhosis, pancreatic hepatitis and non-malignant GI disease.

Not present in those negative for the Lewis blood group determinant.

CA125

Monitoring ovarian carcinoma

 

Raised in patients with ascites, pleural effusions or free fluid in the pelvis

Raised in patients with congestive heart failure

Raised in benign renal and liver disease and other adenocarcinomas

Mildly raised in menstruation and the first two trimesters of pregnancy

Can be raised in endometriosis

CA15-3

Monitoring breast cancer

Lung, colon, ovary

Raised in benign liver, breast, ovarian disease

AFP

Diagnosis and monitoring of hepatocellular carcinoma and germ cell tumours

Gastric and other GI (oesophageal, pancreatic)

Raised in pregnancy and neonates

Raised in benign liver disease

PSA

Diagnosis and monitoring of prostate carcinoma

 

Also elevated in benign prostatic conditions

Increases with age (as prostate size increases)

Elevated in UTI, catheterisation, prostatitis or other prostate manipulation

hCG

Diagnosis and monitoring of germ cell tumours and gestational trophoblastic neoplasia

Lung

Raised in pregnancy

Transiently elevated with cannabis use

LDH

Diagnosis and monitoring of germ cell tumours

 

Elevated in cardiac disease and benign liver disease

Elevated in some anaemias relating to non-malignant disease

INTERFERON GAMMA RELEASE ASSAYS (IGRA) FOR LATENT TB TESTING.

Written by Stephen Rimmer on .

The QuantiFERON-TB Gold In Tube and the T-SPOT are two in-vitro tests for measuring cell-mediated immune responses to peptide antigens from mycobacteria. These antigens, ESAT-6, CFP-10 and TB7.7 (p4) (which is used only in QFT-G) are absent from all BCG strains and from most non tubercular mycobacterial strains (NTMs) with the exception of M. kansasii, M. szulgai and M. marinum. Individuals infected with M. tuberculosis complex organisms (M. tuberculosis, M. bovis, M. africanum, M. microti, M. canetti) have mononuclear cells in their blood that recognise these mycobacterial antigens. This recognition process leads to the stimulation and secretion of IFN-γfrom sensitized T-cells. The detection and quantification of IFN-γ, measured by enzyme-linked immunoassay (Quantiferon) or enzyme-linked immunospot (T-SPOT), forms the basis of these tests – detectable as early as two weeks after infection with M. tuberculosis.

Both tests are intended for use in conjunction with risk assessment, radiography, and other medical and diagnostic evaluations.  QuantiFERON Gold-IT is the laboratory recommended method for routine screening of patients with a normal lymphocyte count.   T spots are recommended in specific circumstances (see below).