Download High Preoperative CA 15-3 Concentrations Predict Adverse

Clinical Chemistry 50:3
559 –563 (2004)
Cancer Diagnostics
High Preoperative CA 15-3 Concentrations
Predict Adverse Outcome in Node-Negative and
Node-Positive Breast Cancer: Study of 600
Patients with Histologically Confirmed
Breast Cancer
Michael J. Duffy,1,2,3* Catherine Duggan,4 Rachel Keane,2,3 Arnold D.K. Hill,2,3
Enda McDermott,2,3 John Crown,5 and Niall O’Higgins2,3
Background: CA 15-3 is the most widely used serum
marker in breast cancer. Currently, its main uses are in
the surveillance of patients with diagnosed disease and
monitoring the treatment of patients with advanced
disease.
Methods: Preoperative CA 15-3 concentrations were
measured prospectively in 600 patients with histologically confirmed breast cancer. Marker concentrations
were related to patient outcome by both univariate and
multivariate analysis.
Results: After a median follow-up of 6.27 years, patients
with high preoperative concentrations of CA 15-3 (>30
units/L) had a significantly shorter overall survival
pattern than those with low concentrations. As a prognostic factor, CA 15-3 was independent of tumor size,
axillary node status, and patient age. As well as being
prognostic in the total population of patients, CA 15-3
also predicted outcome in different subgroups of patients, including those with both node-negative and
node-positive disease, those who were both estrogen
receptor (ER)-negative and ER-positive, and those
younger and older that 50 years of age. CA 15-3 was also
predictive of outcome irrespective of the type of adjuvant therapy administered, i.e., whether adjuvant hormone therapy, adjuvant chemotherapy, or radiotherapy
was administered.
Conclusion: Assay of CA 15-3 is a relatively inexpensive, convenient, and noninvasive method for evaluating prognosis in newly diagnosed breast cancer patients.
© 2004 American Association for Clinical Chemistry
The CA 15-3 assay measures the protein product of the
MUC1 gene. MUC1 protein is a large transmembrane
glycosylated molecule containing three main domains,
a large extracellular region, a membrane-spanning sequence, and a cytoplasmic domain [for reviews, see Refs.
(1, 2 )]. Although the physiologic function of MUC1 is
unclear, the glycoprotein has been implicated in cell
adhesion, immunity, and metastasis (1, 2 ). Compared with
healthy breast tissue, MUC1 is present in higher concentrations but less glycosylated in breast carcinoma (2 ).
Currently, CA 15-3 is the most widely used serum
marker for breast cancer (3 ). Its main applications include
the surveillance of patients with diagnosed breast cancer
and monitoring therapy in advanced disease (1 ). In the
follow-up of patients with diagnosed breast cancer, increased CA 15-3 was found either before or at the time of
recurrence in ⬃70% of cases (4 ). For monitoring the
treatment of advanced disease, CA 15-3 concentrations
were found to decrease in almost 70% of patients with
chemotherapy-induced disease regression and to increase
in 80% of patients with progressive disease (4 ).
Existing histologic (tumor size, tumor grade, and axillary node status) (5 ) and biological [e.g., urokinase plasminogen activator, plasminogen activator inhibitor-1
Departments of 1 Nuclear Medicine and 5 Medical Oncology, St. Vincent’s
University Hospital, Dublin, Ireland.
2
Department of Surgery, Conway Institute of Biomolecular and Biomedical Science, University College Dublin, Dublin, Ireland.
3
Dublin Institute of Molecular Medicine, Dublin, Ireland.
4
Department of Epidemiology, Mathematics and Statistics, Wolfson Institute of Preventive Medicine, Charterhouse Square, London, UK.
*Address correspondence to this author at: Department of Nuclear Medicine, St. Vincent’s University Hospital, Elm Park, Dublin 4, Ireland. Fax
353-1-2696018; e-mail [email protected].
Received August 15, 2003; accepted December 19, 2003.
Previously published online at DOI: 10.1373/clinchem.2003.025288
559
560
Duffy et al.: CA 15-3 in Breast Cancer
(PAI-1),6 cathepsin D, and HER-2] (6, 7 ) prognostic factors
for breast cancer all require tumor tissue. Clearly, the
availability of a circulating prognostic factor, especially if
it provided independent data and was prognostic within
subgroups defined by traditional criteria, would be of
value in breast cancer.
Previously, both we (8 ) and others (9 –14 ) reported that
patients with increased preoperative concentrations of CA
15-3 had a worse prognosis than those with low concentrations. The aim of this investigation was to confirm and
extend our original findings, using both a larger number
of patients (n ⫽ 600) and longer follow-up (median, 6.27
years). In this study, we also investigated the prognostic
impact of CA 15-3 in different subgroups of patients with
breast cancer.
Materials and Methods
patients
A total of 647 patients with a histologic diagnosis of breast
cancer and attending the Breast Clinic at St. Vincent’s
University Hospital Dublin over the period July 1981
through November 1999 had preoperative CA 15-3 concentrations measured. Patients were excluded if they
had a previous diagnosis of breast cancer or if CA 15-3
was not determined in the 6 weeks before surgery. Of
these, 47 had incomplete data on either tumor size or
nodal status and were excluded from the study. All
patients underwent either modified radical mastectomy
or local excision combined with external beam radiotherapy. Data relating to tumor size, axillary node involvement, estrogen receptor (ER) status, and patient age are
summarized in Table 1.
A summary of the adjuvant treatments administered is
shown in Table 2. The median follow-up time was 6.27
years. Of the 600 patients investigated, 368 were also
included in our previous study (8 ). However, these patients were subjected to additional follow-up, whereas 232
new patients were included.
assays
Serum CA 15-3 was measured by ELISA (ES300/Elecsys
2010; Roche Diagnostics). Between-assay variation was
⬍6% for commercial control sera (Preci Controls; Roche
Diagnostics). CA 15-3 concentrations were stratified using
a cutoff value of 30 units/L because we had previously
shown that this is the optimum cutoff point (8 ). Tumor
concentrations of ER were also determined by ELISA
(Abbott Diagnostics). The cutoff point for ER was 200
fmol/g of tumor tissue. All of these assays were carried
out by either qualified clinical chemists or laboratory
technicians.
6
Nonstandard abbreviations: PAI-1, plasminogen activator inhibitor-1;
ER, estrogen receptor; HR, hazard ratio; CI, confidence interval; and CEA,
carcinoembryonic antigen.
Table 1. Pathologic, biochemical, and clinical
characteristics of cancers investigated.
Tumor size, cm
0–2
2–5
⬎5
Nodal status
Negative
1–3 positive
4–10 positive
⬎10 positive
ER status
Negative
Positive
Unknown
Patient age
⬍50 years
ⱖ50 years
Patient age (subgroups), years
25–29
30–34
35–39
40–44
45–49
50–54
55–59
60–64
65–69
70–74
75–79
80–84
85–89
n
%
208
341
51
34.7
56.8
8.5
290
126
122
62
48.3
21.0
20.3
10.3
161
344
95
26.8
57.3
15.8
209
391
34.8
65.2
3
9
40
71
86
89
74
71
59
60
26
8
4
0.5
1.5
6.7
11.8
14.3
14.8
12.3
11.8
9.8
10.0
4.3
1.3
0.7
statistics
Nonparametric analysis was performed because CA 15-3
did not follow a gaussian distribution. The Kruskal–
Wallis test was used for relating CA 15-3 concentrations to
both tumor size and nodal involvement, whereas the
Mann–Whitney U-test was used for relating CA 15-3
concentrations to both ER status and patient age. Cuzick’s
(9 ) test for trend was used to determine whether there
was a statistically significant trend of increasing CA 15-3
Table 2. List of adjuvant treatments administered
Treatment
n
%
No therapy
Hormone therapy alone
Radiotherapy alone
Chemotherapy alone
Hormone ⫹ chemotherapy
Hormone ⫹ radiotherapy
Chemotherapy ⫹ radiotherapy
Hormone ⫹ chemotherapy ⫹ radiotherapy
Unknown
42
122
51
26
39
99
45
88
88
7.0
20.3
8.5
4.3
6.5
16.5
7.5
14.7
14.7
561
Clinical Chemistry 50, No. 3, 2004
values across groups (tumor size and increasing nodal
involvement).
Analysis of events (death as endpoint) was performed
by Cox regression analysis (10 ). Hazard ratios (HRs) with
95% confidence intervals (CIs) were used to convey the
effects. All P values were two-sided. Multivariate analysis
was performed with Cox proportional hazard regression
(10 ). All factors that were significant at the 0.05 level in
the univariate analysis were included in the multivariate
proportional hazard model. Stepwise and backward regressions were used to obtain the final model.
Results
relationship between ca 15-3 and tumor and
patient characteristics
CA 15-3 concentrations were significantly higher in patients with larger tumors (P ⫽ 0.002) and in patients with
increasing nodal burden (P ⫽ 0.004). Cuzick’s test for
trend demonstrated a significant increase in CA 15-3
across these groups for tumor size (P ⬍0.0001) and for
nodal burden (P ⬍0.0001). There was no difference in CA
15-3 concentrations in patients who were ER positive or
negative, but concentrations were significantly higher in
patients 50 years or older compared with those younger
than 50 (P ⫽ 0.03). Concentrations were also higher in
patients who were axillary node positive compared with
those who were axillary node negative (P ⫽ 0.004). A
detailed breakdown on the distribution of CA 15-3 concentrations in relation to tumor size, patient age, axillary
nodal status, and ER status is shown in Table 3.
relationship between ca 15-3 and overall
survival
As shown in Fig. 1 and Table 4, patients with high CA
15-3 (⬎30 units/L) had a worse overall survival pattern
than those with low concentrations of the marker. This
prognostic impact of CA 15-3 was clearly seen by both
univariate and multivariate analysis (Table 4). In multiTable 3. Median and mean CA 15-3 concentrations in
different subgroups.
CA 15-3, units /L
Variable
Tumor size, cm
0–2
⬎2–5
⬎5
Age at diagnosis
⬍50 years
ⱖ50 years
Axillary node status
Negative
Positive
ER status (n ⫽ 505)
Negative
Positive
n
Median
Mean
208
341
51
20.0
21.0
26.0
20.8
24.2
37.2
209
391
19.0
21.0
22.8
24.9
290
310
19.0
21.0
21.2
26.9
161
344
20.0
21.0
24.1
24.5
Fig. 1. Overall survival according to serum CA 15-3 concentrations in
600 patients with breast cancer.
Thin line, CA 15-3 ⱕ30 units/L (n ⫽ 489); thick line, CA 15-3 ⬎30 units/L (n ⫽
111). HR ⫽ 2.16 (CI, 1.55–3.03); P ⬍0.0001.
variate analysis, the prognostic benefit of CA 15-3 was
independent of tumor size, axillary node status, and
patient age. When used as a continuous variable, CA 15-3
concentrations also predicted adverse outcome (P
⬍0.0001).
The prognostic value of CA 15-3 in different subgroups
of patients with breast cancer is summarized in Table 5.
Of particular significance was the finding that CA 15-3
predicted outcome in patients without histologic evidence
of metastasis to axillary nodes (Fig. 2). However, CA 15-3
was also prognostic in other subgroups, including nodepositive patients, in those who had both ER-positive and
-negative tumors, in those with tumors between 2 and 5
cm in size, and in those who were both younger and older
than 50 years. In contrast, CA 15-3 failed to correlate with
outcome in patients with small tumors, i.e., ⬍2 cm in
diameter.
As shown in Table 6, CA 15-3 was also prognostic
irrespective of the type of adjuvant therapy administered,
i.e., whether patients received adjuvant hormone therapy,
adjuvant chemotherapy, or radiotherapy. Although the
number of patients not given any therapy postsurgery
was small (n ⫽ 42), high CA 15-3 concentrations also
appeared to be associated with shortened overall survival
in this untreated group.
Discussion
As mentioned above, existing histologic and biological
prognostic factors for breast cancer all require tumor
tissue. In this study, we both confirm and extend our
previous findings on the prognostic value of serum CA
15-3 in breast cancer (8 ). Our previous report included 368
patients with a median follow-up of 3.28 years (8 ). In
contrast, this study includes 600 patients with a median
follow-up of 6.27 years. Among the most significant
562
Duffy et al.: CA 15-3 in Breast Cancer
Table 4. Comparative prognostic value of CA 15-3, nodal status, tumor size, patient age, and ER status.
Univariate analysis
Multivariate analysis
Variable
HR (95% CI)
P
HR (95% CI)
P
CA 15-3
Nodal statusa
Tumor size
2.16 (1.55–3.03)
1.79 (1.31–2.44)
1.99 (1.46–2.08)
⬍0.0001
⬍0.0001
⬍0.0001
1.95 (1.2–3.07)
1.54 (1.04–2.77)
2.05b (1.31–3.21)
3.97c (1.96–8.0)
0.004
0.003
0.002
⬍0.0001
ER statusd
Patient agee
0.66 (0.47–0.91)
1.11 (1.04–1.19)
⬍0.03
0.001
1.17 (1.08–1.26)
0.0001
For nodal status, node negative was compared with node positive. For tumor size, patients were divided as follows: 0 –2 cm, 2–5 cm, and ⬎5 cm.
Patients with tumors 2–5 cm in size relative to those with tumors 0 –2 cm in size.
c
Patients with tumors ⬎5 cm in size relative to those with tumors 0 –2 cm size.
d
ER status was not included in the multivariate analysis because status was known in only 505 of 600 patients investigated.
e
Patient age was treated as a continuous variable.
a
b
differences between this and our previous report are the
inclusion of more patients and longer follow-up, CA 15-3
was prognostic in the node-negative subgroup of patients.
Another difference is that in the present study, CA 15-3
predicted outcome in ER-negative patients, whereas in
the earlier investigation it failed to do so (8 ). Furthermore,
we report for the first time that preoperative CA 15-3
concentrations predict outcome irrespective of the type of
adjuvant therapy administered.
Other groups have also found that high preoperative
CA 15-3 predicts adverse outcome in patients with breast
cancer (11–16 ). In two of these studies, only small numbers of patients were investigated (⬍100) and multivariate
analysis was not used (11, 12 ). Ebeling et al. (14 ), however, studied 1046 patients and found that preoperative
concentrations of both CA 15-3 and carcinoembryonic
antigen (CEA) were prognostic in breast cancer. In multivariate analysis, CEA retained its prognostic impact, but
CA 15-3 lost its value. Similarly, Canizares et al. (13 )
found that CA 15-3 was prognostic by univariate analysis
but not by multivariate analysis. In contrast to these
findings (13, 14 ) and in agreement with our study,
Kumpulainen et al. (16 ) recently reported that CA 15-3 is
an independent prognostic factor in breast cancer. It is of
interest that the two studies reporting a prognostic value
for CA 15-3 based on multivariate analysis both used 30
units/L as the cutoff point, whereas the reports failing to
find an independent prognostic impact used 40 (13 ) and
25 units/L (14 ).
In our study, CA 15-3 was also prognostic when we
used a cutoff point of 25 units/L, but at this lower cutoff
concentration, the prognostic impact was less than at 30
units/L [HR ⫽ 1.45 (P ⫽ 0.03) vs 2.16 (P ⬍0.0001)].
Similarly, in this investigation, CA 15-3 was prognostic
when we used a cutoff point of 40 units/L (HR ⫽ 2.65; P
⬍0.0001), but at this high cutoff, only 8% of the patients
would be regarded to have a poor outcome.
The most important group of patients with breast
cancer for which new prognostic factors are required is
the axillary node-negative subgroup. Currently, urokinase plasminogen activator and PAI-1 are the only validated biological prognostic factors for this subgroup (17 ).
However, unlike CA 15-3, which can be measured in
serum, assays of urokinase plasminogen activator and
Table 5. Prognostic value of CA 15-3 in different subgroups
of patients with breast cancer.
Subgroup
HR (95% CI)
P
Node negative
Node positive
Tumor size 0–2 cm
Tumor size ⬎2–5 cm
Tumor size ⬎5 cm
ER negative
ER positive
Age ⬍50 years
Age ⱖ50 years
2.43 (1.36–4.33)
1.81 (1.20–2.76)
1.51 (0.62–3.66)
1.93 (1.26–2.94)
2.14 (0.98–4.70)
1.88 (1.04–3.41)
2.28 (1.43–3.64)
2.98 (1.64–5.46)
1.89 (1.26–2.84)
0.003
0.004
NSa
0.002
0.06
0.03
0.007
0.001
0.005
a
NS, not significant
Fig. 2. Overall survival according to serum CA 15-3 concentrations in
290 patients with axillary node-negative breast cancer.
Thin line, CA 15-3 ⱕ30 units/L (n ⫽ 252); thick line, CA 15-3 ⬎30 units/L (n ⫽
38). HR ⫽ 2.42 (CI, 1.35– 4.34); P ⫽ 0.003.
Clinical Chemistry 50, No. 3, 2004
Table 6. Prognostic value of CA 15-3 in different subgroups
of patients with breast cancer based on adjuvant
therapy administered.
Adjuvant treatment
HR (95% CI)
P
Hormone therapy
Chemotherapy
Radiotherapy
No therapya
2.25 (1.50–3.38)
1.8 (1.11–3.08)
2.61 (1.71–3.99)
6.63 (1.47–29.70)
0.0004
0.03
⬍0.0001
0.03
5.
6.
7.
a
Results from the group receiving no adjuvant therapy should be interpreted
with caution because of small numbers (n ⫽ 42).
PAI-1 require tumor tissue. In this investigation, we
showed that preoperative CA 15-3 concentrations are a
significant prognostic factor in this subset of patients.
Similar findings were reported recently by Gion et al. (15 ).
Although histologic factors such as tumor size, tumor
grade, and lymph node status have been the cornerstone
of assessing cancer prognosis for decades, emerging data
suggest that circulating markers can provide additional or
independent data. Thus, tumor markers such as ␣-fetoprotein, human chorionic gonadotropin, and lactate dehydrogenase were recently incorporated into the Union
Internationale Contre le Cancer (UICC) staging system for
germ-cell tumor of the testis (18 ). Furthermore, a consensus conference of the American Joint Committee on Cancer (AJCC) recently recommended that preoperative CEA
concentrations should be added to the staging system for
colorectal cancer (19, 20 ).
8.
9.
10.
11.
12.
13.
14.
15.
In conclusion, our study shows that CA 15-3 is both an
independent prognostic factor and prognostic in different
subgroups of patients with breast cancer. For node-negative patients, CA 15-3 concentrations could be of use in
combination with other factors in deciding whether adjuvant chemotherapy should be administered. In nodepositive patients, those with high CA 15-3 could be
considered for more aggressive treatments. Clearly, CA
15-3 has the potential to help with individualized therapy
in patients with breast cancer.
16.
17.
18.
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