Virtual Surveillance Visits with Symptom, Serum CA-125 Review May Offer Alternative for Ovarian Cancer Recurrence Detection.

In patients with ovarian cancer and pretreatment elevated CA-125 who achieved remission after frontline therapy, most recurrences are detected by rising CA-125 levels or symptoms, according to Monica Janke, MD. As such, virtual surveillance visits with review of symptoms and serum CA-125 may offer a reasonable alternative to in-person visits requiring a physical exam.¹

Data from a retrospective study examining the utility of symptom review, serum CA-125, and physical exam in the detection of disease recurrence, showed that 42.2% of patients had suspected recurrence based on several modalities, 89.0% had elevated CA-125 at the time of their recurrence, and 93.6% of patients had elevated CA-125 and/or symptoms present at the time of recurrence. Notably, 96.3% of those who had abnormal physical exam findings also had elevated CA-125 or symptoms present at the time of their recurrence.

"The rapid implementation of telemedicine in the COVID-19 pandemic motivated us to examine the utility of ovarian cancer recurrence detection methods, most particularly the physical exam,” Janke said. “[In our analysis,] we wanted to try to answer of the question of what we might be missing if unable to perform physical exam. It seems that in this specific group of patients at our institution, physical exam may not add a substantial amount of value when there are alternative modality tools available, including symptom review and serum CA-125, which can be reviewed virtually with patients. This opens a door for us; it may be possible to see ovarian cancer surveillance going virtual in some way, shape, or form."

In an interview with OncLive® during the 2022 SGO Winter Meeting, Janke, a third-year resident, Obstetrics and Gynecology, at Rogel Cancer Center, Michigan Medicine, University of Michigan, discussed the potential role of, or opportunity for, virtual surveillance care for patients with ovarian cancer in the midst of the COVID-19 pandemic and beyond.

OncLive®: Could you provide an overview of your retrospective analysis evaluating the role of virtual surveillance care for patients with ovarian cancer?

Janke: This is a retrospective study of 109 patients with recurrent ovarian cancer. We sought to investigate the utility of the various detection methods that we use in ovarian cancer surveillance; [these] typically [include] a physical exam, symptom review, and serum CA-125.

Our study population included patients with pretreatment elevated CA125 who had achieved remission after primary therapy and then had recurrence. 

Overall, the summary of our findings is that most patients had elevated CA-125 or symptoms present at the time of their recurrence. For our population, [these rates] were 89.0% for elevation in CA-125 and 93.6% for elevation in CA-125 and/or symptoms, respectively. 27 patients or 24.8% had [abnormal] physical exam findings present at the time of recurrence. Of those patients with abnormal physical exam findings, 96.3% also had elevated CA-125 or symptoms. In other words, [only] 1 patient of the 109, which [equates to] 0.9%, had recurrence detected by physical exam findings alone.

Could you shed light on the patient population included in the analysis and the methods used? Were there any additional findings you wanted to highlight?

Regarding the patient population of our study, most patients were white (89.0%) and non-Hispanic (99.1%). The majority of patients had advanced-stage disease— 67.0% had Stage III disease and 23.9% had Stage IV disease. The median time to recurrence from completion of primary treatment was 12 months (range 3-65 months). The median overall survival was 56 months (95% CI 46-79 months) as censored by last follow-up visit or death.

Regarding the methods, we included patients with primary ovarian, fallopian tube, or peritoneal cancer. Patients were included if they completed standard of care treatment with surgical resection and platinum doublet chemotherapy, had no evidence of disease after completion of treatment, and had recurrence of disease confirmed with imaging or biopsy. Patients were excluded if they did not have pretreatment elevated serum CA125 or a complete medical record. Recurrence detection modalities were defined as concerning symptoms reported by the patient, clinically relevant rise in CA125 levels, abnormal physical exam findings, or other. “Other” was denoted if imaging studies were obtained for reasons other than suspected recurrence and recurrence was incidentally identified. Recurrence was incidentally found with imaging obtained for reasons other than suspicion of recurrence, categorized as “other,” in six (5.5%) patients.

Could you expand on the need for this study in this disease, especially in light of the COVID-19 pandemic? How has medicine shifted to incorporate virtual surveillance care?

The optimal surveillance strategy for the detection of recurrent ovarian cancer remains unclear, particularly in the setting of the COVID-19 pandemic and its residual effects on the delivery of patient care. Our results are similar to other studies in the past that have investigated the utility of physical exam in the diagnosis of recurrent ovarian cancer. However, there has never been a more crucial time to critically analyze the value of physical exam with the surge of telemedicine right now. The threat of viral transmission has brought in-person patient care under scrutiny and left providers contemplating the true necessity of services.

Proposed strategies for the incorporation of telemedicine in the care of gynecologic cancer patients during the COVID-19 pandemic included transitioning routine follow-up or surveillance visits to virtual-based consultation. If the potential of telemedicine is to be maximized in delivering high-value care of ovarian cancer patients in the pandemic era, gynecologic oncology providers and patients alike should be armed with the knowledge of the relative utility of recurrence detection methods to inform surveillance strategies, and this is what I believe our data has shed light on.

Is there an optimal surveillance strategy for those with this disease?

We still do not know, and ultimately it will likely still include a combination of modalities. Our data indicate that for patients who have pretreatment elevated CA-125 and who have achieved remission after having primary therapy, most will have a recurrence detected by elevated CA-125 or symptoms. Again, for our cohort, that was greater than 90%. These patients could be reasonably considered or offered to have virtual surveillance visits that include review of symptoms and CA-125. Realistically, virtual visits could be alternated with in-person visits that include physical exam, and these visits could remain on the timeline currently recommended for surveillance of ovarian cancer.

What is your take-home message to your colleagues? Is there any next steps for this research?

This is a small retrospective study and thus is not likely to be practice changing. However, I do believe that this research got a lot of people thinking. The pandemic has [raised] so many practical questions for gynecologic oncology providers and patients alike. I think our results may inform the safety of virtual surveillance visits in this patient population, and therefore give a practical option for follow up in our current clinical landscape. In the future, I think it is important to gauge what patients' experiences are with virtual visits. I think that the incorporation of virtual visits for surveillance is dependent on patient satisfaction with telemedicine, and thus determining their desires and perspectives regarding virtual care is important.

Reference

1. Janke M, Santiago S, Straubhar A, Uppal S. The utility of physical examination in ovarian cancer recurrence detection: a retrospective analysis informing virtual surveillance care. Presented at: SGO Winter Meeting; January 27-29, 2022; Olympic Valley, CA. Accessed February 1, 2022.