Cea level

Inflammation, a virus, many things other than cancer.  His is barely out of normal, and as mentioned, it can get into the thousands.  Sit tight, and wait for further testing.  

My CEA spiked from 3.2 to 4.5 in a month last week after finishing chemo so I had a CT scan and nothing was found. My hypothesis is that it was exercise-induced but I don't have the proof for that - but maybe a strong correlation. It is rough to deal with the uncertainty and worry but the CT scan should provide welcome evidence.

Like the OP, my CEA levels never returned to normal after surgery (modestly elevated in the mid-4's) and has been steadily, slowly rising after year one to 6.5 recently.

When CEA gets above 35 you can be pretty sure it's cancer.  Above 10 you need to look hard.   Above 5 - you can just worry a lot and contemplate the uncertainty.  

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I have some doubts about the OPs report.  Of the 3 CEA measurement systems I've reviewed, all have a resolution at low levels of 0.1 ng/ml, so you might get a reading of 6.9 or 7.0 but you'd never see a report of 6.97.  Also, those 3 systems have a CV(coefficient of variation) around 3 to 5% of reading in the <20 range.   So a reading of '7.0' might mean that 95% of actual values w/ that reading fall between[ 6.3 and 7.7] (2CVs or 2 standard deviations).  I find it unlikely that any new test has a repeatable accuracy to 0.01ng/ml, but PLEASE post the name of the test method from the lab sheet if you have it.

CEA is a family of half a dozen similar glycoproteins. with cell-cell adhesion properties and some modulate immune response.   These glycoproteins can be produced by a number of organs with either inflammation or cysts or polyps or duct blockages (benign or malignant), including thymus, thyroid, pancreas, gallbladder, lungs, the entire digestive tract from esophagus to rectum, breast, prostate, ....  Some external factor impact CEA (smoking roughly double blood level, lithium elevates CEA).   Recent review papers suggest that it is not worthwhile using CEA tests on smokers as they are too erratic.  CEA levels rise slightly with age (about 1ng/ml between 20-70yo) [roughly from 2 to 3 median], and are slightly higher in males.  Hepatitis A & B may elevate CEA.

Benign polyp blockages of the colon can cause elevated CEA, COPD, liver cirrhosis, pancreatitis, gallbladder blockage can elevate CEA.   All this considered, colorectal cancer is the most prevalent cause of elevated CEA for non-smokers.

The 97.5% reference level of CEA is .59 at age 50 and <4.12 at age 70.  Any reading above 6, is into the top 1 percentile, even considering the 95% CV error band.  It's not normal and likely SOMETHING is going on.   But what?  Maybe you have a benign cyst on your kidney or a gallstone... 

The CEA test is accurate at measuring CEA (within the CV limitations) but is not an accurate diagnostic.  We need two concepts to understand this.  Sensitivity and specificity.  https://en.wikipedia.org/wiki/Sensitivity_and_specificity

Sensitivity is the fraction of true-positive results.  For example, the fraction of patients have recurrence who are detected as having high CEA.   Specificity is the number of true-negative results. The fraction of recurrence-free patients who get a low-CEA reading.  Each number has a value from 0 to 1 (think of this as 0% vs 100%).   A perfect diagnostic test has <1, 1>, 100% of recurrence is detected positive, and 100% of non-recurrences are detected as negative.  A random test would have a result of <0.5, 0.5> - half wrong.

The selectivity&specificity vary with the level chosen. If you set the cutoff low, at 1.0 then you catch almost everyone with cancer (sensitivity high) but you also get a lot of false-positives (low specificity).  If you choose a high level like 10.0 as the cutoff, then you get low sensitivity (you miss cancers) but you get fewer false-positives or higher specificity.

Most papers use a level of 5ng/ml as a marker for elevation, other levels have been tested.  A large-scale review paper reports that singe-reading CEA tests for recurrence have <sensitivity, specificity> of:

At 2.5ng/ml cutoff <0.95, 0.80>

At 5.0ng/ml cutoff <0.71, 0.88>

At 10 ng/ml cutoff <0.68, 0.97>

The Cochrane review paper (a highly respected medical organization) concludes that single-reading tests of CEA should only be used with a cutoff of 10.0ng/ml since the specificity is too low otherwise.  Note that this misses about a third of recurrences!

http://cochranelibrary-wiley.com/doi/10.1002/14651858.CD011134.pub2/abstract

Some studies that consider pre-operative CEA show that sensitivity of post-op CEA test is almost meaningless if the patient had elevated pre-operative CEA.  IOW ~<0.431, 0.618> . at CEA 5.0 cutoff.  Useless!

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Let's consider a simple numerical example.   Assume 1000pt with stage I, II, or III cancer after surgery with curative intent have a ~25% probability of recurrence.  With a 5.0 ng/ml cutoff that stats are <0.71, 0.88>

So 71% of the 250 recurrences are detected, but (1-0.88) 12% of the 750 non-recurrences test positive too

The test caught 178 of the 250 with recurrence (missed 72) but also produced 90 false positives!

Results are much worse if we only consider patients with high pre-surgery CEA, then you are more likely to be a false-positive than a true positive at 5.0 level (which is what I'm hoping for).

CEA level is a cr*ppy diagnostic [sorry for the technical language].  It isn't useful except as a sort of vague indicator.  Either that cancer MAY be recurring, or that a treatment MAY be working.  Currently, all the medical organization guidelines (NCCN, ASCO, ASCR) use CEA levels *or* increases, exclusively to trigger imaging exams, and not as a diagnostic for treatment.  This strategy is slightly useful since CTs and PET scans irradiate the body enough that repeated use increases the odds of causing cancer.

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Does high postoperative CEA mean anything given all the false negatives and false positives?   Yeah - unfortunately having a high post-operative CEA puts you in a cohort where most recurrences appear.   The figures vary by stage, but roughly 30% of pt have a high post-op CEA, and that 30% has a majority of recurrences. We are at the high-risk ends of our pools.  In effect, it increases your odds of recurrence by a factor of 2 to 5-ish (more at lower stages, and that's a very squishy number).

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So why don't they do CEAs end CTs every couple months?  Catch recurrence earlier?  Increased surveillance does find recurrence more often, and at a point when surgery is possible more often, BUT it doesn't improve mortality.  So it just causes extra surgery on a subset who are going to die anyway.

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A recent UK/Oxford national study reports that the RATE of CEA increase is a better test.  They suggest an increase of about 1.0 ng/ml per month as the critical level during the first year and an unspecified somewhat lower rates in later years.

The very large scale Dutch "CEAwatch" study also used rates of CEA increase.  They tested CEA every 2 months.  Any 20% increase bi-monthly triggered a test at the next month.  If that was also elevated, it triggered imaging.

As a test, CEA stinks badly.  Not only does it have poor diagnostic value, but it's non-specific.   You might have something other can cancer causing the elevation.  It's not far removed from using a dowsing rod or casting runes.

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There are some tests available (Colvera and cancerSeek, maybe others) that promise better selectivity and specificity while they detect specific cancers by gene expressions and not this glycoprotein from most anywhere.  Good luck getting a prescription; it's not part of the guideline yet so many docs won't order it.

Kazenmax said:

low CEA

My oncologist doesn't bother with CEA measures. He said it's just not definitive. When I was first diagnosed (Stage 3 Colorectal), my CEA was 1.1 and it's never been over 2.0

There's so much we can worry about! Try to take it easy and don't diagnose. 

k

My CEA levels were always below <.05 at my first blood test.  It did go up some during treatment but always stayed in the normal range.  My doctor told me that the CEA level doesn't represent me good for some reason.  I'm not sure why some do and some don't.  Still when my blood tests come around yearly I'll have them take it - knowing that it will come out normal anyway.

Kim

Annabelle41415 said:

Levels

My CEA levels were always below <.05 at my first blood test.  It did go up some during treatment but always stayed in the normal range.  My doctor told me that the CEA level doesn't represent me good for some reason.  I'm not sure why some do and some don't.  Still when my blood tests come around yearly I'll have them take it - knowing that it will come out normal anyway.

Kim

+Annabelle41415

>>My CEA levels were always below <.05 at my first blood test.

That is a VERY unusual number.  CEA test typically have a resolution of 0.1, and an accuracy around 0.2. I've never seen a result reported to 2 digits.

>>It did go up some during treatment but always stayed in the normal range.

0.05 is below the normal reporting range.

My CRC returned in my left lung. It was found at my 1 year CT scan. My oncologist does my annual CEA test and it's been normal range. I have confidence in my oncologist. He monitors all my other blood be work. He follows a very rigorous schedule, otherwise we would not have found the returned cancer. He specifically said CEA is not a good test for me so I suppose I fall in that be low percentage of people.

My oncologist is not Dr. Welby but I trust his judgement. That being said I have always gotten second opinions for everything.

K

Any test sequence is built upon assumptions, specifics, and realities.  We have treated  my wife's mCRC for over 8 years depending on more blood tests* - testing more frequently AND with more markers.  We often only scan every year or so, more when needed.  Our doctors don't have any survivors like my wife.

The medical literature shows that much more predictive information can be squeezed  out of extra kinds of blood tests, beyond "a CEA", with more and better data.  It is possible to improve the underlying medical conditions and "noise", the sampling and the analyses.  Used skillfully, more high quality data, more frequently means better analyses with more answers (and questions).

One of the things that limits conventional medical views are the iatrogenic injury(s) to the dataset as well as the patient.  Cyclical Folfox, Folfiri, Xeloda, etc. treatments at maximum tolerated dose (MTD), damage and inflame tissue and organs enough to greatly distort bloodwork, even for many months after chemo.   Some of this distortion can be reduced with secondary treatments, typically diet and supplements.  We often avoided distortion pretty much in toto with milder, continuous immunochemo with serious supplementation.

Also a lot of mortality with improved detection is linked to lack of timely, well coordinated advanced treatments in an advanced multimodal treatment series, typically in multiple institutions or jurisdictions.   Basically even when patients have a pretty clear idea of what's going on, they are likely to deteriorate and die because of inadequate knowledge and timeliness on lifesaving advanced treatments "somewhere else", or even interference (drs, insurance).  Doctors send you home to die, because they don't know or don't tell where there are better answers. You have to hump it fast to find the better doctors, answers and possibilities before you deteriorate beyond elgibility or operability.

...So why don't they do CEAs end CTs every couple months?  Catch recurrence earlier?  Increased surveillance does find recurrence more often, and at a point when surgery is possible more often, BUT it doesn't improve mortality.  So it just causes extra surgery on a subset who are going to die anyway.

In complex situations like advanced cancer, there is a kind of self fulfilling circularity to failure and futility, where each missed or untimely step penalizes or sabotages subsequent steps.  In the more advanced treatment series, prescient, timely improvements and critical steps need to be taken before windows of opportunity close.  Most patients miss multiple trains, or are pushed off the platform by obsolete conventionalities in the "standard of care".   We are able to fulfill my wife's needs with more bloodwork and fewer (but critical high quality) scans.

* most frequent add-ons to a basic CBC with diffs+CEA+CMP(chem12 or 20):  CA199, AFP, LDH, GGTP, HgbA1C, ESR, hsCRP, calcium(with 50K vitamin D3), potassium (with IV vit C), PT/INR, total protein A/G.  Most of these are cheap and should be in a Chem25 or Chem32, "superchemistry" package

less frequent and initial addons:  ferritin, cerruloplasmin, fibrinogen, quantitative D-dimer, 25 hydroxy vitamin D, bilirubin, TSH, fT3, prolactin (for long term cimetdine tx), G6PD (for the initial IV vitamin C), CA125 (rare), CA72-4; some are in a good superchemistry package