Vallerie Gordon BSc, MD, FRCPC
Medical Oncologist
Assistant Professor
University of Manitoba
&
CancerCare Manitoba
Conflict of Interest Disclosure:
Type of Affiliation/Financial
Support
Name of Commercial
Organization
Self
Spouse or
immediate
family
Consultant
nil
nil
Speaker Bureau
nil
nil
Grants/Research Support
Unrestricted educational grant
Roche Pharmaceuticals
x
nil
Advisory Board Membership
Roche Pharmaceuticals
x
nil
Honorarium Recipient
nil
nil
Stockholder (Not as part of Mutual
Fund)
nil
nil
Trustee/Director
nil
nil
Other (Describe):
nil
nil
Objectives:
 At the end of this session participants will be able to
recognize the use and potential for misuse of tumour
markers to:
1. Identify or diagnose disease.
2. Monitor patients for response to treatment of disease.
3. Assess for recurrence of disease.
Examples of Tumour Markers
Tumour Marker
Cancer
Use
AFP (Alfafetoprotein)
Liver cancer and germ cell
tumours (testicular and
ovarian)
Testing on blood
To help diagnose liver Ca and germ cell tumours,
follow response to treatment, to stage,
prognosticate and for response to treatment and to
identify recurrence of germ cell cancers
B2M
Multiple myeloma, CLL
and some lymphomas
Blood test – to prognosticate and follow response to
treatment
Beta-hCG
Choriocarcinoma and
testicular cancer
To assess stage, prognosticate and follow response
to treatment and identify recurrence
CA15-3(CA =
Breast Cancer
To assess treatment response
CA19-9
Pancreatic , gallbladder,
bile duct, gastric and colon
cancers
Blood test – to follow for treatment response or
progression
CA125
Ovarian cancer
Blood test – for assessment of response to
treatment, assessment for recurrence
carbohydrate
antigen)
Tumour Marker
Cancer
Use
Calcitonin
Medullary thyroid
cancer
Blood test – to aid diagnosis, assess for treatment
response, and assess for recurrence
CEA
Colorectal and
breast cancer
Blood test – to assess for progression, or treatment
response in colon cancer and breast cancer, and
assess for recurrence in colon cancer
Chromogranin A
(CgA)
Neuroendocrine
tumours
Blood test – to help with diagnosis, assessment of
treatment response, and evaluate for recurrence
Immunoglobulins
Multiple myeloma
and Waldenstom
macroglobulinemia
Blood and urine (SPEP & UPEP) – to diagnose
disease, assess response to treatment and watch for
recurrence
LDH
Germ cell tumours
To assess stage, prognosis, and response to
treatment
PSA
Prostate cancer
Blood test – to help with diagnosis, assess response
to treatment, and watch for recurrence
Thyroglobulin
Thyroid cancer
Blood test – to evaluate response to treatment and
watch for recurrence
Cancer of Unknown Primary?
 What is CUP? A cancer that has been thoroughly
worked up diagnostically with no confirmed diagnosis
 With CUP, the tumour markers will often be assessed
at presentation by the medical oncologist, and if
elevated, they may be useful to follow treatment
response
 Like in colon cancer, would suggest test pre each cycle
 For Diagnostic purposes?
Utility?
 Cancer of uncertain Primary
 In the setting of widespread metastatic disease diagnosis
can be challenging
 Tumour markers are helpful only with a clear assessment
of the extent of disease and suspected diagnosis to point
in the direction of the most common diagnosis
 Should be done after all other staging complete
(imaging)
Colon Cancer: CEA +/- CA19-9
 Preoperatively in resectable disease - in known colorectal
cancer - may be helpful to assess for CEA levels (identify
secretory disease)
 Adjuvant disease setting
 CEA Every 3 months for 3 years, then guidelines do not recommend,
but at discretion of medical oncologist may check every 6 months
for additional 2 years
 Metastatic disease setting
 No clear guidelines, but CEA and CA19-9 often checked pre each
cycle to follow for progression between scans
 Expect initial rise in one or other with treatment, then expect it to
fall if effective
 Absolute value less important than the trend generally
Why CA19-9?
 If both CEA and CA19-9 are decreasing or stable -
highly supports a “lack of progression” of disease
 Often elevated with peritoneal involvement
Pancreas, Gall Bladder, Biliary tract,
and Gastric Cancers & CA19-9
 For assessment of metastatic disease on treatment to
assess response
 Checked prior to each cycle of treatment for indication
of disease progression
 May be useful for detection of recurrence after
resection but currently no guidelines recommending
use (no proven quality of life or survival benefit)
Breast Cancer: CA15-3 & CEA
 Useful to monitor disease progression when treating
metastatic disease
 Not useful for diagnostic purposes generally
 Expected trends:
 As with CEA in colon cancer, values may increase
initially, then should fall if responding to treatment
 Absolute number is not important, the trend over a few
cycles is the important message
 Generally with each assessment:
 On endocrine therapy – every 2 – 3 months
 On chemotherapy – pre each cycle
Prostate Cancer and PSA
 Screening:
 Still an area of contention
 Canadian Urologic Association (CUA) suggests PSA be
tested for screening purposes, not supported by the US
group
 Canadian Cancer Society suggested a discussion rather
than routine PSA screening
 Generally checked every 3 – 6 months after surgery to
assess for biochemical recurrence
 Metastatic disease – generally monitor with each
assessment on treatment
 Endocrine therapy – every 2 – 3 months
 Chemotherapy – prior to each cycle
Ovarian Cancer and CA125
 Not useful for diagnosis generally, but in setting of
unclear, potentially operable, peritoneal disease may
play a role preoperatively
 In metastatic disease may help to determine treatment
response – again, check pre treatments with each
evaluation
 Following surgery and chemotherapy, may aid in early
diagnosis of recurrent disease – checked with each reevaluation
Testicular or Germ Cell Tumours:
AFP & b-hCG
 Checked at diagnosis or with suspected diagnosis
 Post surgical: used to assess for recurrence if elevated
preoperatively – guidelines recommend evaluation by
oncologist with set intervals postoperatively
 Post operatively, expect that if no residual disease, the
levels should normalize
 AFP – should do so in 25 – 30 days (depends on value at
presentation)
 b-hCG – should do so in 7 -10 days
 Postoperative chemotherapy – used to monitor for disease
response and expect the values to fall as for post operative
decline
 Metastatic disease – used to assess for response to therapy
Neuroendocrine Tumors:
chromogranin (CgA) and u5HIAA
 Chromogranin - Checked in the post resection period
for high risk disease first every 3 months, then every 6
months
 For patients on treatment, check with each reevaluation – generally every 3 months
 Urine 5HIAA – checked less frequently and requires
dietary changes prior to the test
 Chromogranin - Must be ordered by a medical
oncologist in Manitoba
 Not done in Manitoba – samples are sent for evaluation
in USA by Mayo clinic from Manitoba currently