As reported by Esselen et al in JAMA Oncology, cancer antigen 125 (CA-125) tests and computed tomography (CT) scans for surveillance in women with ovarian cancer continue to be used routinely, although their benefit has not been proven and the practices have significant quality-of-life and economic implications for patients.
The investigators attempted to examine the use of CA-125 tests and CT scans in clinical practice before and after a 2009 randomized clinical trial showed that surveillance testing resulted in poorer quality of life without improvements in survival in women with ovarian cancer in clinical remission. Although the Society of Gynecologic Oncology guidelines consider CA-125 testing optional and discourage the use of radiographic imaging for routine surveillance in this patient population, the 2015 National Comprehensive Cancer Network (NCCN) Guidelines® recommend routine CA-125 testing for those whose CA-125 levels were elevated at diagnosis and CT scanning as clinically indicated, wrote the investigators.
The prospective cohort included 1,241 women with ovarian cancer in clinical remission after completion of primary cytoreductive surgery and chemotherapy at 6 National Cancer Institute–designated cancer centers between January 1, 2004, and December 31, 2011. These women were followed through December 31, 2012. The mean age of the study patients was 59 years, and 1,112 women (89.6%) were white.
The primary outcome was the use of CA-125 testing and CT scans in the first year after remission. Secondary outcomes included time to retreatment with chemotherapy or radiotherapy after a documented doubling of CA-125 levels and the costs associated with surveillance testing (using 2015 Medicare reimbursement rates).
No Major Differences Before and After 2009
The investigators reported there was no significant difference in surveillance testing in the periods before and after 2009. During 12 months of surveillance, the cumulative incidence of patients undergoing 3 or more CA-125 tests was 86% before 2009 vs 91% after 2009 (P = .95; the cumulative incidence of patients undergoing more than 1 CT scan was 81% before 2009 vs 78% after 2009 (P = .50). Furthermore, among the 511 women whose CA-125 markers doubled, there was no significant difference in the time to retreatment with chemotherapy before and after 2009 (median, 2.8 vs 3.5 months; P = .40).
Cost of Surveillance
During the 12-month surveillance period, the mean and median number of CA-125 tests performed per patient was 4.6 and 4.0, respectively. The mean and median number of CT scans performed per patient was 1.7 and 1.0, respectively. The U.S. population surveillance cost estimate for this group was approximately $1,999,029 for CA-125 tests and $14,195,618 for CT scans.
The investigators concluded: “Although a randomized clinical trial demonstrated that surveillance testing results in poorer quality of life without improvements in survival, our results demonstrate that the recommendation to avoid routine surveillance testing has not been adopted into clinical practice in the United States. Similarly, although the routine use of CT scans has been strongly discouraged by guideline committees, CT scans appear to be routinely used, at significant cost.”
The study was funded by grants from the National Cancer Institute and the Cancer Prevention and Research Institute of Texas.
Katharine M. Esselen, MD, MBA, of the Division of Gynecologic Oncology, Beth Israel Deaconess Medical Center, Boston, is the corresponding author of The Lancet article.
The content in this post has not been reviewed by the American Society of Clinical Oncology, Inc. (ASCO®) and does not necessarily reflect the ideas and opinions of ASCO®.