Professional Documents
Culture Documents
CONTINUING EDUCATION
W
hen patients are presented with a tumor marker
laboratory value, they often ask about its meaning. indications in specific diseases.
Oncology nurses should be prepared to describe 2. List examples of factors that may affect the reliability of
the significance of various tumor markers and help patients to tumor marker values.
understand the debate surrounding their use in making clinical 3. Examine the differences in application of tumor marker
decisions. Leading medical societies have formed committees information depending on the disease.
to review the scientific literature and publish guidelines on the
use of tumor markers. However, this process is slow, often
spanning years, and in the interim, assays of reputed tumor Deanna Sanchez Yamamoto, RN, MS, CS, ANP, AOCNP, is a rheu-
matology/oncology nurse practitioner at Santa Clara Valley Medical
markers may become available before sufficient evidence Center in San Jose, CA; Pamela Hallquist Viale, RN, MS, CS, ANP,
supports their use in clinical practice. The recommendations AOCNP, is a nurse practitioner in the Hematology/Oncology Depart-
from published guidelines on the appropriate use of tumor ment at Camino Medical Group in Sunnyvale, CA; Karen Roesser,
markers may differ among medical societies and may add to RN, MS, CNS, AOCN ®, is an oncology clinical nurse specialist at
the confusion (Sturgeon, 2002). CJW Medical Center in Richmond, VA; and Albert Lin, MD, PhD, is
As a result, oncology nurses must be aware of these in- a medical oncologist at Santa Clara Valley Medical Center. (Submit-
consistencies, understand how and when individual tumor ted May 2004. Accepted for publication November 29, 2004.) (Men-
markers are used, and stay informed about new tumor mark- tion of specific products and opinions related to those products do
ers. Patients can become aware of tumor markers from the not indicate or imply endorsement by the Oncology Nursing Forum
Internet, lay literature, and support groups; therefore, oncol- or the Oncology Nursing Society.)
ogy nurses should be as knowledgeable about tumor markers Digital Object Identifier: 10.1188/05.ONF.1013-1025
Prostate cancer
• PSA Screening, monitoring Benign prostatic hypertrophy, prostatitis 0–4 ng/ml
• Percent-free PSA Diagnosis, staging Benign prostatic hypertrophy The greater the value, the less likely
a cancer; no established criterion
Bladder cancer
• NMP22 Monitoring Recent invasive genitourinary procedure, < 10 U/L
urinary tract infection, renal or bladder
stones, chemotherapy
• BTA Monitoring Recent genitourinary trauma (cystoscopy), Normally not detected
renal or bladder stones, urinary tract
infection
Lung cancer
• NSE Diagnosis, monitoring – < 13 ng/ml
• CEA Monitoring, prognosis See colorectal cancer. –
• CYFRA 21.1 Diagnosis, prognosis, monitoring Chronic hepatitis, pancreatitis, chronic No international reference standard
airway obstruction
• CA 125 Diagnosis, prognosis – No international reference standard
Colorectal cancer
• CEA Monitoring Cigarette smoking, peptic ulcer, in- < 3 ng/ml in nonsmokers and < 5
flammatory bowel disease, pancreatitis, ng/ml in smokers
hypothyroidism, biliary obstruction,
cirrhosis, COPD, pulmonary infections,
chronic renal failure
Pancreatic cancer
• CA 19.9 Diagnosis, monitoring Pancreatitis, cirrhosis, acute cholecystitis, < 70 U/ml
extra hepatic cholestasis
Breast cancer
• ER/PR Determine endocrine therapy. – Positive (favorable)
• HER2/neu Determine anthracycline trastu- – IHC 1+ negative and IHC 2+ →
zumab therapy. FISH
• CA 15.3, CA 27.29 Monitoring Chronic hepatitis, liver cirrhosis, tuber- < 31 U/ml
culosis, sarcoidosis, systemic lupus
erythematosus
Ovarian cancer
• CA 125 Monitoring Peritonitis, endometriosis, nonmalignant 0–35 U/ml
ascites, menstruation, pregnancy
AFP—alpha-fetoprotein; B-hCG—beta-human chorionic gonadotropin; BTA—bladder tumor antigen; CA—cancer antigen; CEA—carcinoembryonic antigen;
COPD—chronic obstructive pulmonary disease; ER—estrogen receptor; FISH—fluorescence in situ hybridization; IHC—immunohistochemistry; LDH—lac-
tate dehydrogenase; NMP22—nuclear matrix protein 22; NSE—neuron-specific enolase; PLAP—placental alkaline phosphatase; PR—progesterone receptor;
PSA—prostate-specific antigen
Note. From “Tumor Marker Tests” (www.vh.org/adult/patient/cancercenter/tumormarker/index.html), by Virtual Hospital, 2005. Copyright 2005 by Virtual Hospital
and the University of Iowa. Adapted with permission.
7,000
4 ng/ml, but 75% of men with prostate cancer have an ab-
6,000 normal PSA test (Goolsby). Once individuals are diagnosed
5,000 with prostate cancer, measurement of PSA levels is useful in
4,000 determining the success of treatment and can help to detect
3,000 disease recurrence.
2,000 The use of PSA as a screening tool has not been adopted
1,000 universally by all medical organizations (Canto & Slawin,
1,000 2002; Frankel, Smith, Donovan, & Neal, 2003). The Ameri-
can College of Physicians, American College of Preventive
16 3
30 3
/1 03
/2 03
/1 03
/2 03
/9 3
/2 03
1/ 003
20 4
2/ 004
17 4
3/ 004
04
9/ 200
9/ 200
12 200
1/ 200
2/ 200
10 /20
10 /20
11 /20
11 /20
12 /20
20
Medicine, and U.S. Preventive Services Task Force do not
/2
/2
2/
5/
3/
6/
3/
2/
4
8
1
9/
04
04
04
04
0
0
/2
/2
/2
/2
patients (Duffy, 1999; Emens & Davidson, 2003). Neverthe-
26
25
24
3
/2
4/
6/
8/
less, American Society of Clinical Oncology guidelines have
10
supported the use of tumor markers to help in identifying Date
breast cancer treatment failure where disease is not measur-
Case Study
able (Bast et al.).
In April 2004, a 49-year-old female was diagnosed with primary peritoneal
Ovarian Cancer papillary serous carcinoma and underwent surgical resection to remove a 10
x 16 cm mass in her pelvis. She was started on carboplatin and paclitaxel every
Ovarian cancer is the leading cause of death for all female three weeks for a total of six cycles. The serial cancer antigen 125 shows a
cancers of the reproductive system and is estimated as the decline after optimal debulking surgery and then returns to a normal range after
fourth most-common cause of mortality for women in 2005 the fourth cycle of chemotherapy, indicating a good response to therapy.
(American Cancer Society, 2005b). Seventy-five percent
of patients with ovarian cancer present with advanced dis- Figure 3. The Use of Cancer Antigen 125 Values to Monitor
ease (i.e., stage III and IV), and despite aggressive therapy, Ovarian Cancer
60%–85% experience a recurrence. The amount of residual
disease present after initial debulking surgery is directly
related to survival rates; the five-year survival rates for stage evident (Guppy & Rustin; Vaidya & Curtin). A serial decrease
III and IV are 20%–50% and 5%–20%, respectively (Vaidya in CA 125 levels has been associated with response to treat-
& Curtin, 2003). ment (Guppy & Rustin). Disease progression can be defined
The serum tumor marker CA 125, a large glycoprotein, is as a doubling from nadir or a doubling from a persistently
the best and most widely researched marker for ovarian cancer high level despite chemotherapy (Guppy & Rustin; Vaidya
(Guppy & Rustin, 2002; Sturgeon, 2002; Vaidya & Curtin, & Curtin). In a study of 225 patients, a doubling of CA 125
2003). CA 125 is present throughout the reproductive system above the upper normal limits after initial chemotherapy
and is found in healthy ovarian tissue and on the epithelium of had a sensitivity of 86% and a specificity of 91% for disease
the endometrium, the endocervix, and fallopian tubes, as well as progression (Vaidya & Curtin). The Standards, Options,
the mesothelial cells of the pleura, peritoneum, and pericardium and Recommendations project guidelines have suggested
(Guppy & Rustin; Vaidya & Curtin). CA 125 can be elevated remeasuring the CA 125 level after two to three weeks if it
in more than 90% of women with advanced ovarian cancer was previously normal to confirm the increase and calculate
and in 40% of patients with any primary cancer with extensive doubling (Sturgeon, 2002). A 25% or greater rise in CA 125
intra-abdominal disease (Guppy & Rustin). The increase can be in three serial samples is almost 100% specific for disease
directly related to tissue destruction, inflammation, and vascu- progression, after which additional evaluation is needed and
lar invasion (Guppy & Rustin). Because CA 125 is associated a computed tomography scan should be performed (Guppy
with inflammatory cells, the antigen often can be elevated in & Rustin; Sturgeon).
peritonitis, endometriosis, and nonmalignant ascites, as well as Timing the measurement of CA 125 is critical because the
other benign conditions, including menstruation and pregnancy antigen can be elevated after surgery or paracentesis (Guppy
(Guppy & Rustin; Vaidya & Curtin). & Rustin, 2002). The half-life of CA 125 is approximately six
Surgery and chemotherapy remain the treatments of choice days, with an expected decline for three to six weeks (Guppy
for epithelial ovarian cancer, and disease monitoring is needed & Rustin). Currently, no evidence supports early interven-
to determine a patient’s response to chemotherapy treatment. tion solely based on rising CA 125 because the level will not
Using traditional diagnostic imaging is difficult because improve the survival of relapsed patients (Guppy & Rustin;
microscopic disease is undetectable. CA 125 is a valid and Sturgeon, 2002). Although a normal CA 125 level can be
effective tool for monitoring treatment response and has reassuring, it cannot exclude the presence of a tumor (Guppy
become a cornerstone in the management of ovarian cancer & Rustin; Vaidya & Curtin, 2003).
(Guppy & Rustin, 2002) (see Figure 3). As much as 80% CA 125 does not have a role in ovarian cancer screening
concordance exists with the CA 125 level and clinical course or diagnosis because of its low sensitivity and specificity
of patients undergoing treatment for ovarian cancer (Vaidya (Sturgeon, 2002). The prognostic value of CA 125 following
& Curtin, 2003). surgery and during chemotherapy has been established in
In approximately 70% of patients, rising CA 125 may be various trials but currently has not been adopted as part of
the first indication of relapse (Guppy & Rustin, 2002; Vaidya the tumor-node-metastasis staging system (Sturgeon). Other
& Curtin, 2003). CA 125 elevation can occur in an asymp- tumor markers have been investigated for use in ovarian can-
tomatic patient one to six months before becoming clinically cer, but none has achieved practical clinical application. Many
References
Alizadeh, A.A., Eisen, M.B., Davis, R.E., Ma, C., Lossos, I.S., Rosenwald, tumor markers into clinical decision-making. Seminars in Oncology, 29,
A., et al. (2000). Distinct types of diffuse large B-cell lymphoma identified 286–293.
by gene expression profiling. Nature, 403, 503–511. Canto, E.I., & Slawin, K.M. (2002). Early management of prostate cancer: How
Alper, O., Bergmann-Leitner, E.S., Bennett, T.A., Hacker, N.F., Stromberg, to respond to an elevated PSA? Annual Review of Medicine, 53, 355–368.
K., & Stetler-Stevenson, W.G. (2001). Epidermal growth factor receptor Cheung, K.L., Graves, C.R., & Robertson, J.F. (2000). Tumour marker
signaling and the invasive phenotype of ovarian carcinoma cells. Journal measurements in the diagnosis and monitoring of breast cancer. Cancer
of the National Cancer Institute, 93, 1375–1384. Treatment Reviews, 26, 91–102.
American Cancer Society. (2005a). Can prostate cancer be found early? Coldman, A.J., Phillips, N., & Pickles, T.A. (2003). Trends in prostate cancer
Retrieved July 8, 2005, from http://www.cancer.org/docroot/CRI/content/ incidence and mortality: An analysis of mortality change by screening
CRI_2_4_3X_Can_prostate_cancer_be_found_early_36.asp?sitearea= intensity. Canadian Medical Association Journal, 168, 31–35.
American Cancer Society. (2005b). Cancer facts and figures, 2005. Correlogic Systems, Inc. (2005). Frequently asked questions. Retrieved July
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CAFF2005f4PWSecured.pdf Doherty, A.P., Bower, M., & Christmas, T.J. (1997). The role of tumour mark-
American College of Preventive Medicine. (2001). Understanding prostate ers in the diagnosis and treatment of testicular germ cell cancers. British
cancer screening: A statement from the American College of Preventive Journal of Urology, 79, 247–252.
Medicine and Medem. Retrieved August 22, 2004, from http://www.acpm Duffy, M.J. (1999). CA 15-3 and related mucins as circulating markers in
.org/pcscreening.htm breast cancer. Annals of Clinical Biochemistry, 36(Pt. 5), 579–586.
Balmer, L.L., & Greco, K.E. (2004). Prostate cancer recurrence fear: The Ebb, D.H., Green, D.M., Shamberger, R.C., & Tarbell, N.J. (2001). Cancer of
prostate-specific antigen bounce. Clinical Journal of Oncology Nursing, childhood: Solid tumors of childhood. In V.T. DeVita, Jr., S. Hellman, &
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pancreatic cancer. Biomedicine and Pharmacotherapy, 54, 400–409. Emens, L.A., & Davidson, N.E. (2003). The follow-up of breast cancer.
Bast, R.C., Jr., Ravdin, P., Hayes, D.F., Bates, S., Fritsche, H., Jr., Jessup, Seminars in Oncology, 30, 338–348.
J.M., et al. (2001). 2000 update of recommendations for the use of tumor Ferrigno, D., Buccheri, G., & Giordano, C. (2003). Neuron-specific enolase
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Credit Hours: 1.4 phatase (PLAP) is not used for every patient. The correct
Passing Score: 80% answer is that PLAP values are distorted in patients who
Test ID # 05-32/5-08 a. Smoke.
Test processing fee via ONS Web site: FREE b. Consume alcohol.
Test processing fee via mail-in form: $15 c. Have extragonadal disease.
d. Have an elevated body mass index.
The Oncology Nursing Society is accredited as a provider 6. The most specific tumor marker currently available is
of continuing education in nursing by the American Nurses a. Alpha-fetoprotein.
Credentialing Center’s Commission on Accreditation and the b. Lactate dehydrogenase.
California Board of Nursing, Provider #2850. c. PSA.
d. Carcinoembryonic antigen (CEA).
1. What is an example of a known tumor marker? 7. Mr. R has completed external beam radiation for early-stage
a. Hypercholesteremia in patients with testicular cancer prostate cancer. His post-treatment PSA level at six months
b. An abnormal chromosome in patients with breast was significantly higher than the level taken immediately
cancer following the end of treatment. The nurse knows that
c. An abnormally enlarged prostate gland in patients with a. Mr. R’s treatment was unsuccessful.
prostate cancer b. Mr. R may be experiencing the “PSA bounce” phe-
d. Clinical finding of abdominal pain on palpation in nomenon.
patients with liver cancer c. PSA values are always highest six to nine months
2. When explaining tumor markers to a patient with prostate post-treatment and are not a concern.
cancer, the nurse correctly informs him that the prostate- d. PSA values post-treatment are generally unreliable
specific antigen (PSA) value and cannot be used to evaluate treatment.
a. Measures only his familial propensity toward develop- 8. The use of nuclear matrix protein 22 as a screening meth-
ing prostate cancer. od for bladder cancer is controversial in part because
b. Only is important prior to the beginning of treatment a. Only advanced disease can be detected reliably by
to predict response to treatment. nuclear matrix protein 22.
c. Only is important as a screening tool to detect early b. False-positive results can occur in patients with benign
prostate cancer occurrence. conditions.
d. Is most sensitive in measuring response to treatment c. Most insurance companies will not cover the cost of
and predicting chance of recurrence. the use of the screening indicator.
3. A patient has been referred to the clinic for evaluation after d. Its reliability is no greater than that of conventional
demonstrating an elevated beta-human chorionic gonado- screening methods, at a much higher cost.
tropin level. Careful history to determine etiology of the 9. CEA is used primarily in patients with colon cancer to
elevation should include questions regarding a. Detect recurrence of disease.
a. History of alcohol consumption. b. Diagnose the presence of disease.
b. Any history of marijuana use. c. Predict prognosis in patients after primary treatment.
c. Any history of diabetes or thyroid condition. d. Direct treatment decisions for patients after initial
d. Concomitant medications currently being taken. diagnosis.
4. An elevated alpha-fetoprotein level is almost always 10. Research demonstrates that patients who have colon can-
specific for the presence of which of the following tumor cers that express the epidermal growth factor receptor
types? a. Have more aggressive disease, with a poorer progno-
a. Germ cell sis.
b. Squamous cell b. Respond best and have the lowest chance of recurring
c. Adenocarcinoma disease.
d. Neuroectodermal cell c. Can tolerate more aggressive, therapy thereby improv-
5. Two nurses are discussing the use of tumor markers for ing their chances of survival.
diagnosis and monitoring of patients with testicular cancer. d. Are notoriously unresponsive to chemotherapy and
One wonders why the marker placental alkaline phos- should be referred to palliative treatment.
Name Telephone #
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