HER2 Support Group Forums - View Single Post - Link to 2007 ASCO guidelines for tumor markers

dlaxague · 11-27-2007, 09:07 PM

Gerri, if you're looking for support for doing tumor marker or scans as part of follow-up after primary disease, you're not going to find it in this guideline. You may find it in this forum - there has been lots of discussion and some excellent points made - for example that there is not good current information to support either view. But this guideline does not recommend tumor markers for follow-up of primary disease. It says:

"2007 recommendation for CA 15-3 and CA 27.29 to detect recurrence after primary breast cancer therapy. Present data do not support the use of CA 15-3 and CA 27.29 for monitoring patients for recurrence after primary breast cancer therapy. There is no change from the guideline published in 2000. Literature update and discussion. Several well-designed studies have shown that an increase in CA 15-3 or CA 27.29 after primary and/or adjuvant therapy can predict recurrence an average of 5 to 6 months before other symptoms or tests. While additional studies have been published since the last ASCO guideline that address the value of these serum markers at detecting recurrence,there are no prospective randomized clinical trials to demonstrate whether detection and treatment of occult or asymptomatic metastases using tumor markers impact on the most significant outcomes (disease-free survival, overall survival, quality of life, toxicity, or cost-effectiveness). Although the assay was approved by the US Food and Drug Administration, the US Food and Drug Administration does not require tests to show clinical benefit if that is not part of the manufacturer's indication. Given the limited evidence, and until clinical benefit is established, present data are insufficient to recommend routine use of CA 15.3 or CA 27.29 for this application. This recommendation is in line with that of the ASCO guideline for follow-up and management of patients with breast cancer."

Me again - There are many oncologists who do use tumor markers and scans as part of follow up after primary disease. At this point, there's no evidence to support using them and so I'd say it remains an individual decision. The users say that it should be better to find a cancer recurrence before symptoms herald its presence, even though the studies, so far, do not support that claim. The non-users point to the studies that show no difference to length of survival nor to quality of life when a recurrence is found with markers before symptoms are present. And they add that doing the tests can cause anxiety and also can lead to more unecessary (and negative) testing. And that a negative test result offers no guarantees.

I am a non-user. While I of course do not like the idea that I could have a recurrence, and I wish that I had more control over my outcome - I find some peace in believing that ultra-vigilance will offer me no benefit. I get my small fix of control-illusion by knowing what symptoms might be worrisome, and knowing to report them if they last longer than two weeks, or sooner if they are severe. This style works for me. I do not have to endure the anxiety of anticipating the test, nor of waiting for the results. I do not have to deal with the heightened level of alert that accompanies "borderline" results. A negative test offers me no reassurance. I know that I could have a negative test today and mets next week. I have given up most illusions of control, which is both scary and at the same time, wonderfully liberating.

Think about what style of medical management works for you. Discuss this with your current oncologist and if you're not satisfied with the answers, get a second opinion. If you want to be ultra-vigilant, you can probably find a provider to assist you in that style of follow-up.

I hesitate to bring this up because it's such a touchy issue (in my experience, smile). But another factor to consider, if you're willing, is stewardship of available resources to pay for the incredibly expensive technology that is now available to us. This does not apply so much to tumor markers, which are relatively cheap, but it does apply to scans done simply to reassure an NED woman after primary disease (I am not talking about people with mets). It's fine to talk of the terrible state of health care in this country and say that we must demand the tests that we "want", expense be damned. But the fact is that we (the big "we" - our society) are not going to be able to afford to do everything for everyone. It's not something that anyone is glad about, but it's a fact that needs to be faced.

I don't have answers. But I do wish that more politicians were brave enough to raise the questions. The solutions are hard, and if they are to provide equitable care to all, those solutions probably must involve rationing of care.

Do you feel that you should try to be a good steward of health care dollars, or do you feel that your primary cancer diagnosis entitles you to whatever you want or feel that you need? I don't ask these questions because I know the answers to them, nor to challenge. I ask them so that we all stop to think about the big picture.

Debbie Laxague

11-27-2007, 09:07 PM	#4
dlaxague Senior Member Join Date: May 2006 Posts: 221	follow-up after PRIMARY breast cancer Gerri, if you're looking for support for doing tumor marker or scans as part of follow-up after primary disease, you're not going to find it in this guideline. You may find it in this forum - there has been lots of discussion and some excellent points made - for example that there is not good current information to support either view. But this guideline does not recommend tumor markers for follow-up of primary disease. It says: "2007 recommendation for CA 15-3 and CA 27.29 to detect recurrence after primary breast cancer therapy. Present data do not support the use of CA 15-3 and CA 27.29<SUP> </SUP>for monitoring patients for recurrence after primary breast<SUP> </SUP>cancer therapy. There is no change from the guideline published<SUP> </SUP>in 2000.<SUP> </SUP>Literature update and discussion. Several well-designed studies have shown that an increase in<SUP> </SUP>CA 15-3 or CA 27.29 after primary and/or adjuvant therapy can<SUP> </SUP>predict recurrence an average of 5 to 6 months before other<SUP> </SUP>symptoms or tests. While additional studies have been published<SUP> </SUP>since the last ASCO guideline that address the value of these<SUP> </SUP>serum markers at detecting recurrence,<SUP></SUP>there are no prospective<SUP> </SUP>randomized clinical trials to demonstrate whether detection<SUP> </SUP>and treatment of occult or asymptomatic metastases using tumor<SUP> </SUP>markers impact on the most significant outcomes (disease-free<SUP> </SUP>survival, overall survival, quality of life, toxicity, or cost-effectiveness).<SUP> </SUP>Although the assay was approved by the US Food and Drug Administration,<SUP> </SUP>the US Food and Drug Administration does not require tests to<SUP> </SUP>show clinical benefit if that is not part of the manufacturer's<SUP> </SUP>indication. Given the limited evidence, and until clinical benefit<SUP> </SUP>is established, present data are insufficient to recommend routine<SUP> </SUP>use of CA 15.3 or CA 27.29 for this application. This recommendation<SUP> </SUP>is in line with that of the ASCO guideline for follow-up and<SUP> </SUP>management of patients with breast cancer.<SUP>"</SUP> Me again - There are many oncologists who do use tumor markers and scans as part of follow up after primary disease. At this point, there's no evidence to support using them and so I'd say it remains an individual decision. The users say that it should be better to find a cancer recurrence before symptoms herald its presence, even though the studies, so far, do not support that claim. The non-users point to the studies that show no difference to length of survival nor to quality of life when a recurrence is found with markers before symptoms are present. And they add that doing the tests can cause anxiety and also can lead to more unecessary (and negative) testing. And that a negative test result offers no guarantees. I am a non-user. While I of course do not like the idea that I could have a recurrence, and I wish that I had more control over my outcome - I find some peace in believing that ultra-vigilance will offer me no benefit. I get my small fix of control-illusion by knowing what symptoms might be worrisome, and knowing to report them if they last longer than two weeks, or sooner if they are severe. This style works for me. I do not have to endure the anxiety of anticipating the test, nor of waiting for the results. I do not have to deal with the heightened level of alert that accompanies "borderline" results. A negative test offers me no reassurance. I know that I could have a negative test today and mets next week. I have given up most illusions of control, which is both scary and at the same time, wonderfully liberating. Think about what style of medical management works for you. Discuss this with your current oncologist and if you're not satisfied with the answers, get a second opinion. If you want to be ultra-vigilant, you can probably find a provider to assist you in that style of follow-up. I hesitate to bring this up because it's such a touchy issue (in my experience, smile). But another factor to consider, if you're willing, is stewardship of available resources to pay for the incredibly expensive technology that is now available to us. This does not apply so much to tumor markers, which are relatively cheap, but it does apply to scans done simply to reassure an NED woman after primary disease (I am not talking about people with mets). It's fine to talk of the terrible state of health care in this country and say that we must demand the tests that we "want", expense be damned. But the fact is that we (the big "we" - our society) are not going to be able to afford to do everything for everyone. It's not something that anyone is glad about, but it's a fact that needs to be faced. I don't have answers. But I do wish that more politicians were brave enough to raise the questions. The solutions are hard, and if they are to provide equitable care to all, those solutions probably must involve rationing of care. Do you feel that you should try to be a good steward of health care dollars, or do you feel that your primary cancer diagnosis entitles you to whatever you want or feel that you need? I don't ask these questions because I know the answers to them, nor to challenge. I ask them so that we all stop to think about the big picture. Debbie Laxague