Kathryn Rainey

Addition of Mesothelin to the CA-125 Test

Central Magnet School

Dr. Laura Lynn Roland

Ms. Eve Harrison

Graduation: May, 2019

 Abstract

Currently, there is no consistently reliable, cost efficient, noninvasive, and regularly

mandated test for ovarian cancer; the present tests are insufficient, and the survival rates
are low. A solution would be to develop better diagnostic tests for earlier diagnosis to
improve prognosis for patients. The CA-125 test is the least invasive screening test
currently being implemented, but it presents many problems; For example, it diagnoses
numerous false positives and negatives. The main problem is that CA-125 can elevate due
to normal bodily functions such as menstrual cycles or diseases like endometriosis.
Luckily, the incorporation of glycoprotein Mesothelin into the CA-125 test may increase
the sensitivity and specificity of the test, meaning that there’s a decrease in false positives
and negatives and an increase in true positives and negatives. Since Mesothelin’s
discovery as a good addition to the test is a recent discovery, its functions are unknown,
but it binds to CA-125 and the levels are highly elevated in women with ovarian cancer.
The addition of MSLN could possibly improve the CA-125 blood test, making the test
more consistent to detect ovarian cancer more efficiently, effectively, and reliably.

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To my parents, for supporting me when I would lose faith in myself

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 Acknowledgements

First, I want to thank my partner, Hannah Cheng, for grinding this out so hard; I’m so

impressed by her drive and proud of her strong role in this process. I couldn’t have asked

for a more enthusiastic and hardworking partner. Next, I want to thank my mentor, Dr.

Khalaf, for the time he put into helping us develop our idea and figuring out what all the

sources meant. I would also like to thank Ms. Harrison for her interest and excitement in

this paper, and for her critiques to improve the content. Lastly, I want to thank Dr. Roland

for being constantly supportive and helping critique this paper.

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 Table of Contents

Chapter 1: INTRODUCTION............................................................................................. 1

Research Questions ......................................................................................................... 1

Define the Problem.......................................................................................................... 1

Research Purpose ............................................................................................................ 1

Background Information ................................................................................................. 2

Possible Treatments......................................................................................................... 3

Purpose of the Paper ........................................................................................................ 4

Chapter 2: REVIEW OF LITERATURE ........................................................................... 5

Ovarian Cancer and Diagnostic Test ............................................................................... 5

Mesothelin ....................................................................................................................... 6

CA-125 and Mesothelin as a Combined Diagnostic Test ............................................... 7

Chapter 3: METHODOLOGY............................................................................................ 9

Purpose Statement ........................................................................................................... 9

Assessment ...................................................................................................................... 9

Search Strategies ........................................................................................................... 10

Materials and Participants ............................................................................................. 10

Protocols ........................................................................................................................ 11

Chapter 4: FINDINGS AND ANALYSIS ........................................................................ 12

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 Findings and Analysis ................................................................................................... 12

Table 1. Specificity and Sensitivity ............................................................................ 14

Table 2. Sensitivity and Specificity of MSLN ............................................................. 15

Table 3. Sensitivity and Specificity of CA-125 .......................................................... 16

Table 4. Sensitivity and Specificity of a Combined Test ............................................ 18

Review Limitations ....................................................................................................... 18

Implications and Directions for Future Research .......................................................... 20

Chapter 5: CONCLUSION ............................................................................................... 23

References ......................................................................................................................... 24

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 List of Tables

Table 1. Specificity and Sensitivity………………………………………………………14

Table 2. Sensitivity and Specificity of MSLN…………………………………………….15

Table 3. Sensitivity and Specificity of CA-125…………………………………………...17

Table 4. Sensitivity and Specificity of a Combined Test…………………………………18

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 Chapter 1: INTRODUCTION

Research Questions

• Is there a way to improve the current diagnostic methods of ovarian cancer to

possibly increase survival rates?

• Will a positive correlation between Mesothelin and CA-125 indicate that the two

could be combined into one screening test for ovarian cancer?

• Will the addition of Mesothelin to the CA-125 blood test result in a higher

sensitivity and specificity alone than CA-125 alone?

Define the Problem

The problem with the CA-125 test is that it’s not an accurate test to detect early

stage ovarian cancer. Scientists are attempting to improve the test, and the biomarker

Mesothelin is something they’re researching to either use it to combine with CA-125 or

completely change the test to focus on Mesothelin. However, since there’s little known

about Mesothelin, and to create a new test is beyond the qualifications of a high school

student, the focus of this paper is to determine if comparing both CA-125 and Mesothelin

will increase the likelihood of them becoming a new test for improved results. Also, if

combined, it will become more successful rather than having an individual test for CA-

125 or Mesothelin.

Research Purpose

The purpose is to determine a correlation between Mesothelin levels and CA-125

levels, if we can combine the original test with detection of Mesothelin levels. Studies

show that CA-125 is elevated during early stage cancer as well as Mesothelin; a
combination of these two biomarkers should help to detect more accurately. If there’s

better detection of early stage ovarian cancer, then it can hopefully increase the survival

rate of those diagnosed, not just for ovarian cancer but mesothelioma, lung cancer, and

pancreatic, which also show elevated CA-125 levels. Comparing research results already

done is a more reasonable task for high school students rather than conducting results

themselves.

Background Information

The problem statement stemmed from a project done in a Biomedical III class,

where it was discovered that there is no consistently reliable, cost efficient, noninvasive,

and regularly mandated test for ovarian cancer. There are three tests used to detect

ovarian cancer: the pelvic exam, transvaginal ultrasound, and, of course, the CA-125 test.

However, all these tests are ineffective, and women find them invasive.

For example, the pelvic exam, is where most early ovarian tumors are difficult or

impossible for any examiner to feel; this means that the patient’s ovarian cancer will not

be diagnosed until later stages, when the problem has become difficult to treat or difficult

to overcome. Another unreliable test is the transvaginal ultrasound, which uses sound

waves to look at the uterus, fallopian tubes, and ovaries by inserting an ultrasound wand

into the vagina to find masses, like tumors, but cannot identify whether the mass is

cancerous or benign. Another reason those tests are not as reliable is because women find

these tests uncomfortable and invasive, so they don’t get regularly checked for ovarian

cancer.

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 Lastly, the most noninvasive test that is being implemented presently is the CA-

125 blood test, which tests for the levels of CA-125, or cancer antigen 125, found in

ovarian cancer cells. However, it’s only real use now is to confirm cancer if a woman is

suspected of having it because doctors know that it’s not the most reliable test, and that’s

why researchers are looking for an improved test. Its many problems include levels of

CA-125 can be elevated by other bodily functions such as a woman’s menstrual cycle,

pregnancy, benign tumors, pancreatitis, pelvic inflammatory disease, or liver disease.

Therefore, high levels of CA-125 do not necessarily correlate with a woman’s risk of

developing ovarian cancer or mean she has ovarian cancer.

Luckily, the protein Mesothelin binds to CA-125, is produced when cancers are

young and in Stage I, and is highly expressed in cancerous tumors. Unfortunately,

research is still being done to learn more about Mesothelin, so scientists are sketchy to

base an entire separate test for that biomarker knowing so little about it. They do know,

however, that there are elevated levels when cancer is present and has less benign results.

If possible, using Mesothelin to develop a new blood test to detect ovarian cancer earlier

and more effectively would be useful in increasing the ovarian cancer survival rate.

Possible Treatments

A possible solution is to combine the CA-125 test with a specific biomarker that

relates to ovarian cancer and can provide a more efficient detection of the cancer.

Another would be to focus of just Mesothelin, but studies have shown that Mesothelin by

itself wouldn’t be as effective as combining it with CA-125.

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Purpose of the Paper

The purpose of this paper, instead of conducting an individual test to find

Mesothelin, is to compare research done from other scientists to determine if a

combination of CA-125 and the biomarker Mesothelin could yield more positive results

for detection and decrease the amount of benign results from just CA-125. The hope is

that the calculations made in this paper will correlate with the idea that a combined test

will be more effective. There will be two tables statistically calculating results; one table

will show the correlation of actual cancer and elevated CA-125, and the other table will

do the same but with Mesothelin instead of CA-125. Once the detected numbers are filled

in the table, specificity and sensitivity will be calculated to see if the results are

successful.

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 Chapter 2: REVIEW OF LITERATURE

Ovarian Cancer and Diagnostic Test

CA-125 is a protein produced by ovarian cancer. The test checks the levels of

CA-125 in the blood, which is the first recognized tumor marker for cancer in the ovaries

(Fritsche, 1998). CA-125 is effective in diagnosing ovarian cancer; studies reveal that it

elevates in women with ovarian cancer. It can identify about 85% of clinically advanced

ovarian cancers, and the deviations in average CA-125 levels can occur well over a year

before diagnosis (McIntosh, 2009). However, it’s considered an ineffective test; CA-12

will elevate in patients with breast, endometrium, gastrointestinal tract, and lung cancer,

as well as benign diseases of the uterus, liver, and gastrointestinal tract and in the ovary

and uterus (Fritsche, 1998). It will also be present during menstrual cycles and

pregnancy.

Additionally, CA-125 suffers from low sensitivity and low specificity used to

diagnose early stage ovarian cancer; meaning that it detects a high number of false

positives and false negatives. Due to this, it detects benign diseases more than actual

high-risk cancers (Huang, 2006). CA-125 can elevate for many other bodily functions

like the menstrual cycle or diseases like endometriosis, pelvic inflammatory disease, or

uterine myoma (American Cancer Society, n.d.). It can also be increased in patients with

breast, lung, liver, endometrium, gastrointestinal, and uterine cancers. The solution for

this problem that scientists are trying to determine is to combine the biomarker CA-125

with another biomarker.

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Mesothelin

Researchers have been conducting studies to see if Mesothelin will prove to be a

better test for early-stage detection than CA-125. The high expression shown in tests

increases the likelihood of more specific detection that can benefit the current situation

(Ho, 2005) of using CA-125. The reason that it’s such an ideal candidate is because it’s

expressed in much higher quantities in patients with tumors versus benign tumors. Due to

the improved accuracy, scientists believe that Mesothelin was a “significant predictor” of

ovarian cancer compared to CA-125 (Ibrahim, 2014).

The problem with using just Mesothelin is that there’s been very little research

done to help scientists understand specifically what it’s used for in the body; it elevates if

a patient has cancer, but that’s the only characteristic researchers understand. So,

researchers for now are focusing on its use for diagnosing. The increased expression is

found through cancer tissues and blood and can also be measured in serum and other

body fluids, including urine, by using ELISA (Kristen, 2016).

However, studies done have concluded that the use of Mesothelin would be more

productive in combination with another biomarker. Cheng says that Mesothelin will

require even more studies to confirm whether Mesothelin will work as an “independent

predictor” (Cheng, 2009). As of right now, also stated by Madeira (2012), Mesothelin

cannot serve as a marker alone for the detection of ovarian cancer, but the combination

with CA-125 may be able to “achieve greater sensitivity” (Madeira, 2012). Therefore,

researchers are presently focusing on finding an adequate protein to combine. As a

screening test, it could more effectively diagnose ovarian cancer, but could improve “in

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combination with another biomarker, especially in the early stages of disease” (Kristen,

2016). It’s a novel tumor target for all scientists studying the effects of Mesothelin for

diagnosing ovarian cancer (Sirois, 2018).

CA-125 and Mesothelin as a Combined Diagnostic Test

Huang (2006) began by talking about how that alone, CA-125 alone is inefficient.

When he and his team ran experiments, they discovered that Mesothelin can be used to

help diagnose ovarian cancer and reduce the prognosis (Huang, 2006). Additionally,

Abdel-Azeez (2010) also showed that Mesothelin and CA-125 were elevated in the

women, and when combined they produced elevated sensitivity levels (Abdel-Azeez).

Kaneko (2009) focused on the workings of CA-125 and Mesothelin together as

well. The team discovered that “the interaction between Mesothelin and CA-125 may

facilitate the implantation and spread of tumors by cell adhesion” (Kaneko, 2009).

Basically, when they bind, the CA125 and Mesothelin will increase in expression, and the

results show that they can become a new agent for diagnosing tumors. He also recognized

that blocking the interaction between the two may reverse metastasis and contribute to

higher survival rates in patients. Scientists are also considering the possibility that

Mesothelin has a higher sensitivity over CA-125 as well as temporal stability.

Furthermore, the combination will better the longitudinal screening program as well as in

a diagnostic setting (McIntosh, 2004).

The need for more research on them as an effective combined diagnostic test is

important to apply this research to an actual test that can better results. This research

“facilitates prioritization of tumor types for future research” to clinically benefit the

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targeting of Mesothelin (Lamberts, 2015) along with other biomarkers. Compared with

the low levels of CA-125 alone, when tested as diagnostic markers using samples

collected at clinical diagnosis, there were healthy high levels of specificity shown (Shah,

2009) for the combined test. Shah (2009) measured levels of Mesothelin and CA-125 in

his meta-analysis and obtained results about the specificity and sensitivity of a combined

test.

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 Chapter 3: METHODOLOGY

Purpose Statement

So far, there is no reliable screening test to detect early stage ovarian cancer.

However, scientists are looking to combine the current CA-125 test with another

biomarker to hopefully improve the diagnostic methods for ovarian cancer and increases

survival rates. In this thesis, there will be research done that compare Mesothelin and

CA-125 and see if together, more accurate results will be found and there will be less

benign detection of ovarian cancer. To determine this, the research will be analyzed,

specifically looking for the specificity and sensitivity of Mesothelin and CA-125. It’s

hypothesized that a positive correlation could indicate that the two could be combined

into one screening test for ovarian cancer.

Assessment

There appears to be no meta-analysis conducted so far about both CA-125 and

Mesothelin by combining multiple resources to calculate the predicted sensitivity and

specificity of each substance alone and together. Though, there have been studies

analyzing the sensitivity and specificity of Mesothelin and CA-125 separately: most of

the research on CA-125 is older with the articles ranging from the 1990s and 2000, and

Mesothelin research is relatively new from 2010 to present, so there’s not much evidence

determining that the combination will be successful. If the two can be shown to improve

the current test together, then there will be an increase in diagnosis and improve ovarian

cancer rates. With the limited research done about them as a combined test, other sources

will be used to see if the combined test will be effective.

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Search Strategies

Most of the research on this topic is from the internet, but using reputable sources

through Google Scholar and verifying if the articles it has pulled up are relevant to the

topic and are trustworthy depending on the website address and institution the study was

conducted in. Due to the little research done on Mesothelin, there’s little put into non-

electronic sources; those that mention Mesothelin are unrelated to this topic or not

specific enough to this thesis. Little selection criteria were used to limit research with a

limited amount of information available. However, sources that targeted Mesothelin as

immunotherapy were not used.

Materials and Participants

A mentor and specialist in oncology, Dr. Waleed Khalaf, and a qualified

statistician, Dr. Kyle Prince, was involved in the analysis of this study. Dr. Khalaf

assisted in interpreting data, finding reliable research, and explaining formatting as well

as how data will be displayed. Dr. Prince assisted in calculating specificity and sensitivity

and arranging it into a data table to show results.

Dr. Khalaf aided in interpreting articles to help find which articles would best

serve the purpose for this thesis, as well as coaching through ideas that were either

impossible to achieve because of time or because there were qualification issues for

certain experiments. Dr Prince will help to find numbers appropriate to use for

calculations for the sensitivity and specificity. The data was extracted from reputable

online sources from numerous scientific articles and experiments done concerning CA-

125 and Mesothelin levels.

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 The materials are the research papers and experiments gathered for background

and results in order to combine the biomarkers. As stated, the research stems from past

studies from the 1990s to present. The information and experiments are all reliable, as

there have been other studies conducted to support the results.

Protocols

The research and information are divided into subcategories: ovarian cancer,

ineffective diagnostic tests of ovarian cancer, specifically the CA-125 test: how it works

and its flaws, Mesothelin, and the CA-125 and MSLN as a combined diagnostic test.

These subcategories will build on previous information presented because the topics

begin broad and become more specific. The first category, ovarian cancer, will provide a

background on its nature and survival rates; it will also explain CA-125 and their relation

(CA-125 elevation during ovarian cancer). The CA-125 diagnostic test section will

explore its flaws and how these flaws make it an unreliable and undesirable test. The

Mesothelin section will discuss information about Mesothelin and its fame as a biomarker

to detect early-stage cancers when combined with other biomarkers; thus, leading to the

next section of Mesothelin and CA-125 as a combined diagnostic test. Though there has

been little research done on the test itself, there will be explanations as to the hypothesis

that together, levels indicating cancer will increase and therefore diagnosis will increase.

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 Chapter 4: FINDINGS AND ANALYSIS

Findings and Analysis

Ovarian cancer currently has the highest mortality rate of gynecological

malignancies. Cheng’s research expresses that an average of 75% of women are

diagnosed in an advanced stage, and the survival rates are between 19-30%. Stages III

and IV are considered advanced, when the cancer has spread to the abdomen or beyond.

Compared to Stage I, where the cancer is concentrated to just within the ovaries, the

chances of survival are lower. The solution is obviously earlier diagnosis, before the

tumor spreads throughout the body; according to the American Cancer Society, if ovarian

cancer were to be diagnosed during Stage I, the survival rate is increased to 92%.

However, the current screening tests to detect ovarian cancer are inefficient.

The current tests include pelvic exams, transvaginal ultrasounds, and, of course,

the CA-125 test. The pelvic exam is just simply an examination of the pelvic region, but

it wasn’t designed to specifically detect tumors. Therefore, it’s easy to overlook masses

that may be present. Transvaginal ultrasounds are scans to examine the inside of the

pelvic region to detect masses; however, the transvaginal ultrasound will detect any mass,

benign or tumor, so it’s reliability and specificity is low. Women are encouraged to

regularly get checked for masses, but many women don’t because they consider the tests

invasive. Therefore, the CA-125 test is considered the most noninvasive tests and one of

the leading screening tests, due to the cost efficiency and accessibility.

Screening tests are medical tests performed on subjects of a population to assess

the likelihood of the members having a disease (Maxim, 2014). They are not the same as

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diagnostic tests, which diagnose a disease. The purpose of a screening test is to find if a

person tests positive for a disease, so they can determine if a diagnostic test is needed.

The CA-125 screening test is supposed to be able to inform a person at possible risk of

ovarian cancer; however, this screening test is ineffective because there are significant

results with either false negatives or false positives. The specificity and sensitivity of CA-

125 is what’s responsible for these results, so in order to reduce the number of false

positives and negatives and increase the numbers of true positives and negatives, we have

decided to combine CA-125 with Mesothelin and calculate the sensitivity and specificity

to increase the effectiveness of the current screening test.

Sensitivity is the test’s ability to correctly designate a person with a positive for

the disease (Maxim, 2014). This means that a high number would correlate with a higher

true positive diagnosis. A test result with a high sensitivity result could indicate that there

are a few false negative results, meaning that there are people with the disease that were

incorrectly diagnosed as disease-free; they were not shown that they are at risk so they

could not take appropriate measures to get it confirmed. However, an adjusted test with

higher sensitivity may result in more false positives and less false negatives but lowering

it could produce more false negatives and less false positives (Maxim, 2014).

Specificity is the test’s ability to correctly designate a subject without the disease

as negative (Maxim, 2014). A high specificity would show a high number of true

negatives and a higher chance for correct diagnosis. A high specificity result could

indicate that there are a few false positive results. Though this is not as much of a serious

issue as a high sensitivity test, the false specificity will show that a subject is positive for

13
a disease and will therefore go through unnecessary diagnostic tests to find a disease that

was never there in the first place. If a test has low specificity, it may create false

positives.

According to Maxim, this table should show logical screening test outcomes:

Table 1. Specificity and Sensitivity

Test Results Subject has disease Subject disease free Subtotal

Positive Correct result False positive Total positive test

results

Negative False negative Correct result Total negative test

results

Subtotal Total subjects with Total subjects disease Total subjects

disease free

A similar table was used once the results were calculated using numbers extracted

from other sources (Madeira 2016, Ibrahim 2014, McIntosh 2004, Lin 2012, Shah 2009).

Maxim discussed the idea of a “Gold Standard” where in an ideal screening test, there

would be 100% specificity and 100% sensitivity. While there’s an impossible chance of

this happening by a screening test, we are looking to find a protein that can combine with

the CA-125 successfully and hopefully increase these numbers to get more accurate

results. Sensitivity and specificity can be calculated by the formulas below:

• Sensitivity: _TP_
TP+ FN
• Specificity: _TN_
TN+FP

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 Research shows that Mesothelin could improve the results of the CA-125 test.

Though there’s little research done on the specific uses, it’s shown to elevate in patients

with ovarian cancer, and it could also work well for immunotherapy and drugs as well as

diagnosis (Lamberts, 2015). It’s intriguing to scientists to try and find a way to

incorporate Mesothelin into therapies and drugs, but now, scientists find that it can be

used in diagnosis for not only ovarian cancer, but lung, pancreatic, uterine cancer and

mesothelioma. It’s elevation and binding to CA-125 is shown to increase the sensitivity

and specificity of the current test, and below, the calculations will be done for

Mesothelin, CA-125, and the combination of the two to compare the reuslts.

Table 2. Sensitivity and Specificity of MSLN

MSLN

Source Sensitivity Specificity

Madeira 49.00% 95.00%

Ibrahim 97.00% 98.00%

Lin 49.30% 94.50%

Shah 44.10% N/A

Qiao 78.60% 83.30%

The numbers found for Mesothelin’s sensitivity were 44.1, 49, 49.3, 78.6, and 97.

The numbers for the quartiles of this data are listed below:

• Q1=46.55

• Median=49.3

• Q3=87.8

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 The interquartile range is needed to find the outliers for the sensitivity, based on

Ibrahim’s (2014) unusually high number. Using the formula, 1.5(Q3-Q1), 1.5(87.8 -

46.55) = 41.25, and 73.15 + 41.25 = 114.4, 97 appears not to be an outlier. The mean of

these numbers is 63.6, but since 97 is relatively higher, calculations were performed

without the 97 and discovered that the mean would be 55.25. This conveys that

Mesothelin has a 63.6% chance of correctly identifying ovarian cancer, or the true

positive rate. This appears to be low, but when combined with CA-125 the number

should improve. Ibrahim’s (2014) highest percentage for sensitivity is considered an

extremely good number; however, the other numbers were considered very low.

The numbers found in Mesothelin’s specificity were 94.5, 95, 98, and 83.3. The numbers

for the quartiles of the data and the mean are listed below:

• Q1=88.9

• Median=94.75

• Q3=96.5

• Mean=92.7

This shows that Mesothelin has about a 92.7% chance of correctly identifying

those without the disease, or the true negative rate. The specificity mean for Mesothelin is

significantly higher than the mean for sensitivity. Therefore, Mesothelin alone can

identify true negatives well.

Table 3. Sensitivity and Specificity of CA-125

CA-125

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 Source Sensitivity Specificity

Madeira 80.00% 75.00%

Ibrahim 97.40% 56.90%

McIntosh N/A 85.00%

Shah N/A 78.80%

The numbers for the sensitivity of CA-125 were found to be 80 and 97.4, the

mean being 88.7. Ibrahim (2014) got another high number for sensitivity and was the

only good calculation. Most of the numbers were poor (under 79), except for the

sensitivity calculations from Madeira (2016) and the specificity from McIntosh (2004).

This means that CA-125 has around an 88.7% chance of correctly identifying the true

positive rate. A sensitivity of 88.7% is considered good, but not great, if in the 90’s.

The numbers found for the specificity of CA-125 were found to be 56.9, 75, 78.8,

85. The numbers are listed below:

• Q1=65.95

• Median=76.9

• Q3=81.9

• Mean=73.93

According to the formula 1.5(81.9 - 65.95) 23.925 and 75 - 23.925= 51.075, 56.9

is not an outlier, though it is significantly smaller than the rest. The test has about a

73.93% chance of correctly identifying the true negative rate. In comparison with

Mesothelin, the numbers for specificity were higher and considered to be greater in

detecting a true negative.

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 For the combined test, the mean was calculated for all the numbers; as shown,

most of the numbers were good results, disclosing the decent result given by Shah ().

Therefore, there’s an improved reading of true positives and true negatives.

Table 4. Sensitivity and Specificity of a Combined Test

MSLN & CA-125 Combined

Source Sensitivity Specificity

Ibrahim 97.40% 98.30%

Shah 98.00% 86.50%

The combination of CA-125 and Mesothelin’s specificity are 97.4 and 98, making

the mean 97.7; the numbers for their specificity were 98.3 and 86.5, making the mean

92.4. Their combination for sensitivity has about a 97.7% chance of correctly identifying

the true positive and a 92.4% chance of correctly identifying the true negative rate. The

combined results showed great numbers and a definite improvement in reliability.

The combination results show that more research should be done on the

combination, as the numbers appear to increase in accuracy. However, there were little

sources to pull from in order to make these calculations, and there should be more meta-

analyses to compare these results with to increase the reliability of these tests to confirm

results and identify more accurate numbers.

Review Limitations

Initially, the idea was to create a new, combined test and conduct an experiment

to determine if it would work; however, since there was a lack of experience to do such

work, the idea ended up having to be revised; the correlation between Mesothelin and

18
CA-125 could not have feasibly been tested by inexperienced youth. The mentor, Dr.

Khalaf, advised that an experiment that in depth would also require more time than given.

It would have taken a whole year to find people willing to participate, and even then,

there would have had limited data focused on only females in Vanderbilt in Franklin.

Therefore, the thesis switched from a Methodology to a Meta-Analysis.

Additionally, the experiment that was initially needed for the original idea proved

to be overqualified for the current level of expertise possessed by the testers. The

participants have not sufficiently learned the amount of knowledge needed to perform

human experiments and testing blood work; not only are they uneducated in that study,

but unqualified without the proper licenses needed.

Since the thesis was revised, it was decided to collect data from other resources

and studies to find calculated sensitivities and specificities for Mesothelin and CA-125.

Unfortunately, a wide variety of numbers were needed in order to calculate and put into

tables, but the research deemed difficult. Google Scholar was used to obtain our

information, but some sources required money to access that could not have been

contributed. Also, resources that were only abstract could not be used, and some articles

that could have related to the thesis only allowed access to the abstract unless part of a

certain institution. The time constraints reduced the amount of time to properly find other

sources or possibly sign up to look at certain restricted articles.

Lastly, even qualified researchers haven’t been able to test the combination of

CA-125 and Mesothelin yet, due to the still limited amount of research available on their

19
combination. So, for unqualified testers, inferences were made on how well the two

combined will do as a revised screening test.

Implications and Directions for Future Research

Mesothelin should be heavily considered to improve the CA-125 test. According

to the calculations found, it increased the chances for a correctly diagnosed patient. Of

course, more extensive research can help to confirm the use of Mesothelin to improve the

current screening test. Also, there was a lack of studies regarding the combination of

Mesothelin and CA-125, which presented difficulties for finding an adequate amount of

numbers to calculate. The increased number of tests increases the reliability of this study

on combined tests, so numbers could be better trusted and hopefully reduce confusion in

high sensitivity or specificity.

As well as a detection biomarker, Mesothelin was also shown to be useful in

developing a combined therapy treatment for patients with cancer, due to the high

concentrations of it in tumors. Research done by Kelly (2012) and Einama (2017) show

that Mesothelin could also develop combined treatments as well as Mesothelin vaccines.

Additionally, more research should be done on other proteins like HE4 and its

potential use for the development of more tests. According to studies, HE4 levels are

elevated by more than 50% of tumors that don’t express CA-125. This combination

enables the detection of malignancies in patients with tumors that are not expressed by

CA-125 alone. However, it’s not as good as Mesothelin for detection, and Mesothelin’s

most useful application would be in combination with CA-125, as said by McIntosh

20
(2004). Abdel-Azeez (2010) agrees that the combination of Ca-125 and Mesothelin

improve the sensitivity compared to CA-125 alone.

Due to the limited access of an abundance of sources, there are possibilities that

we could have missed information, so there should be more meta-analyses conducted in

this area of study because of the high amount of death rates. This could provide a

concentrated source of baseline education for other research, and the compilation of

information could inspire a desire to find more studies or conduct experiments.

Public education regarding cancers would be extremely beneficial; currently,

biomedical; courses are an optional class, and are viewed as a serious course to take for

people interested in a medical field. However, cancer can impact every person’s life, so

it’s important for people to be knowledgeable about certain risks. The most serious aspect

of ovarian cancer is the fact that it’s usually diagnosed in a late stage where there can be

no effective treatment. If more females can understand the importance of having regular

screening tests done, it can increase the likelihood of survival if it can be caught early

enough. This revised screening test, if successful, should be a source of non-invasive

testing to make the female more comfortable; however, since more research needs to be

done on combined screening tests, the invasive ones will stay around for a while. Due to

that, educating women about the importance of regular screening could potentially

motivate them to get the testing done regardless of the invasiveness.

In addition to ovarian cancer, CA-125 is also elevated in patients with

mesothelioma, lung cancer, and pancreatic cancer. If the combination of CA-125 with

Mesothelin proves to improve the detection, it could also improve the early-stage

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detection of those cancers, as well as ovarian cancer. So, more research could improve

the lives of hundreds of thousands more and could increase the survival rate of more than

one cancer.

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 Chapter 5: CONCLUSION

The problem started with the inaccurate CA-125 test used to detect early stage

ovarian cancer. Scientists are attempting to improve the test using a combination of CA-

125 with another biomarker to improve the test. However, since there’s little known

about Mesothelin, the focus of this paper was to determine if comparing both CA-125

and Mesothelin will increase the likelihood of them becoming a new test for improved

results. Studies show that CA-125 is elevated during early stage cancer as well as

Mesothelin; a combination of these two biomarkers should help to detect more

accurately. If there’s better detection of early stage ovarian cancer, then it can hopefully

increase the survival rate of those diagnosed. A possible solution was to combine the CA-

125 test with a specific biomarker that relates to ovarian cancer and can provide a more

efficient detection of the cancer. So, instead of conducting an individual test to find

Mesothelin, research was done to compare research done from other scientists to

determine if a combination of CA-125 and the biomarker Mesothelin could yield more

positive results for detection and decrease the amount of benign results from just CA-125.

The hope is that the calculations made in this paper will correlate with the idea that a

combined test will be more effective. There were tables that statistically calculated results

that showed the correlation of actual cancer and elevated CA-125 and Mesothelin. Once

the detected numbers are filled in the table, specificity and sensitivity will be calculated

to see if the results are successful. This paper also reaches to show the possible

importance of Mesothelin in screening tests for lung and pancreatic cancer and

mesothelioma. Therefore, more research should be done to discover more uses for

Mesothelin in general, including its potential uses of cancer detection and therapy.

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