ABSTRACT
Introduction: Incidental elevations in Carbohydrate Antigen 19-9 (CA19-9) can trigger extensive medical evaluations for malignancy. Though classically associated with pancreatic cancer, CA19-9 is a nonspecific manifestation of multiple benign and malignant disease processes. Case Description/Methods: An asymptomatic, healthy 50-year-old female presented to primary care for an elevated CA19-9 level obtained for pancreatic cancer screening in Asia in 2019. Her evaluation in 2019 included abdominopelvic CT and magnetic retrograde cholangiopancreatography, which were normal. She was offered endoscopic ultrasonography to further evaluate pancreaticobiliary etiologies but was lost to follow-up amid the COVID-19 pandemic. She returned to the US in 2021, and basic laboratory testing and routine cervical cancer screening were performed. She was referred to Gastroenterology (GI) for further evaluation. Cervical cytology revealed atypical endometrial cells, and endometrial biopsy by gynecology was concerning for gastric-type endocervical adenocarcinoma. Transvaginal ultrasound revealed a thickened endometrial stripe, and pan CT revealed duodenal thickening, for which GI performed bidirectional endoscopy without significant abnormalities and no pancreatic or metastatic disease. Repeat CA19- 9 increased. She was referred to gynecologic oncology, where cervical biopsy and pelvic MRI confirmed an endocervical mass. She was diagnosed with Stage IIB gastric-type endocervical adenocarcinoma and underwent hysterectomy and left salpingectomy with adjuvant chemoradiation. Discussion(s): CA19-9 is synthesized in multiple organ systems. Elevations in asymptomatic patients are rarely predictive of pancreatic cancer but may expose patients to unnecessary testing and inadvertent harms without identifying malignancy. Thus, CA19-9 is not recommended for pancreatic cancer screening. Incidental elevations do warrant repeat testing. Benign processes will yield stable or decreasing levels, while rising levels suggest progressive or malignant processes. If concern for pancreatic malignancy is low, a reasonable investigation includes chest X-ray or CT, metabolic studies, hemoglobin A1c, liver and thyroid function panels, abdominopelvic CT or gynecologic cancer evaluation, and any other age-indicated cancer screening. In this case, prior imaging studies suggested low concern for pancreatic cancer. Her subsequent evaluation aligned with this suggested work-up and revealed gynecologic cancer as the ultimate etiology for her elevated CA19-9.
ABSTRACT
INTRODUCTION: At our institution we utilize an Open Access Colonoscopy (OAC) program that allows patients to self-refer for colorectal cancer (CRC) screening and polyp surveillance. Patients are offered the choice of optical colonoscopy or CT colonography (CTC) and the submission is the reviewed for appropriateness. Open access procedures account for approximately 20% of the endoscopic procedures performed at our institution. Following the directive to postpone elective procedures due to the COVID-19 pandemic, our department had 202 OAC patientswhose CRC screening would be delayed. We utilized fecal immunochemical testing (FIT) to provide timely CRC screening to appropriate patients. FIT is a top tier, stool based, CRCscreening test for average risk patients. METHODS: This was an observational study which assessed all patients previously scheduled for CRC screening through a pre-existing OAC program. The rates of FIT eligibility, patient acceptance, patient completion, and results were tracked. RESULTS: A physician reviewed the 202 OAC patient request forms for FIT eligibility. We found 143 patients that were eligible for FIT with the primary exclusions being a personal history of polyps or a significant family history. Our eligibleOAC patients were proactively notified of delays and offered FIT by a nurse. Of the eligible patients, 100 (70%) accepted, 41 (29%) declined and 2 (1%) were unable to be reached. Nine weeks into our initiative, 64 eligible patients (64%) hadcompleted screening with 8 positive and 56 negative tests. Patients with positive FITs received scheduling precedence. Two advanced adenomas were detected in the first six weeks. CONCLUSION: FIT has been used for programmatic CRC screeningby healthcare systems due to low cost and ease of participation.Still, FIT is not widely utilized in many medical systems where patients are often screened opportunistically after presenting forcare via self-referral or referral from their primary care provider. Our findings suggest that the majority of our patients prioritizedtimely CRC screening over a specific modality of screening in a self-referral system. We propose that the utilization of FIT in OAC programs can decrease wait times for screening, particularly during periods of limited resources. This highlightsthe feasibility of FIT in a self-referral OAC program forproviders and health systems working to maintain access to care through streamlining of CRC screening. (Figure Presented) .