Association of CA19-9 and tumor size in treatment monitoring for patients with metastatic pancreatic ductal adenocarcinoma (PDAC).
Authors: Hahn Andrew , Travis Bethnay , Hunter David , Colorafi Abbey , Regan Christina , Bay Curt , Koo Phillip , Dragovich Tomislav , Choti Michael A. , Kundranda Madappa N. , Chang John 
Published: January 2023

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Background: Although modern cancer treatment has significantly prolonged patient’s life, it comes with a high financial cost. Based on an NIH report on Financial Burden of Cancer Care, treating PDAC costs $108K, $18K, and $125K for initial treatment, during follow up, and in last year of life, respectively. Of these, CA19-9 and CT studies are obtained concurrently to evaluate tumor burden whose cost can be reduced by decreasing imaging frequency when CA19-9 remains stable. As a pilot study, we evaluated whether changes in CA19-9, an inexpensive laboratory study commonly used for monitoring treatment response, correlates with tumor size change on imaging studies. A positive correlation may lead us to design future studies to evaluate whether stable CA19-9 can serve as an indicator for stable disease on CT scan such that imaging frequency (and cost) may be reduced. Methods: We retrospectively identified PDAC patients from our tumor registry from 2016 to 2019. Subjects were included if they met the following criteria: 1) diagnosed with PDAC 2) had at least 2+ CA19-9 and CT/MR follow up assessments with the laboratory and imaging studies within one month of each other, and 3) had measurable lesions as defined by RECIST 1.1 criteria. Due to limited resources, we limited the maximum number of lesions to 4 instead of the usual 5 for RECIST 1.1. Two-dimensional orthogonal tumor sizes were measured on axial images with the largest cross-section. Changes in the values were obtained serially (from the immediately prior study). Nonparametric correlations (Spearman’s rho) were used to evaluate monotonicity. The significance level was set at p < 0.05. Results: We screened 300 subjects from the tumor registry and identified 23 subjects suitable for our study. 13 subjects were female and 10 were male with ages ranging from 35 to 84. We identified 55 target lesions and 128 assessments (with both CA19-9 and imaging) from the 23 subjects. We analyzed the log absolute and log relative change in CA19-9 with change in tumor area. When absolute CA19-9 value, absolute change in CA19-9, and relative change in CA19-9 were tested against the absolute change in tumor size, the correlation was significant for the absolute value and absolute change of CA19-9 (p < 0.01), but not for relative change of CA19-9 (p < 0.11). When tested against relative change in tumor size, all three values were highly significant (p < 0.001). Conclusions: Our finding of direct correlations between changes of CA19-9 and relative change of tumor size on imaging suggests that CA19-9 can serve as a surrogate measure of relative change of tumor burden for patients undergoing treatment. This provides motivation for future studies evaluating the possibility that stable CA19-9 can represent stable tumor burden such that expensive imaging studies may be obtained at longer time intervals to reduce financial cost to patients.