INTRODUCTION:

Colorectal cancer (CRC) in recent years is ranked third in terms of the most common type of cancer worldwide ¹. Colorectal cancer is the primary cause of cancer-related mortality and quickly becoming a significant public health issue². Each year, CRC patients in the world amounted to 18.1 million, and 9.6 million of them died in the world³. CRC is estimated to increase to 60% by 2030, with the incidence of new cases of 2.2 million and CRC patients who died of 1.1 million. (Arnold et al., 2017). CRC is also one of the public health problems considered in Indonesia. In the world, Indonesia obtained third rank regarding CRC cases with low survival rates⁵.

Several risk factors might cause the incidence of CRC increased continuously each year, including age, race, gender, and family history⁶. In addition, the environmental factors, smoking, poor nutrition, and food contamination account for 65% of cancer causes⁷. The US Preventive Services Task Force (USPSTF) recommends that each individual perform CRC screening at age 50 and do periodic checks until the age of 75 years⁸. Colorectal carcinogenesis process characterized by genetic and epigenetic changes that turn normal cells into cancer cell^9–11. CRC develops of the proliferation and self-renewal of colorectal epithelial cell adenocarcinoma¹². CRC that developed from a benign neoplasm is one of the cancers that can be prevented before it develops at an advanced stage¹³. However, patients with CRC found much to do an inspection when it has been at an advanced stage, due to mostly there was no sign and symptoms at early stage of the disease¹⁴. Early detection of CRC becomes essential to prevent the CRC progress¹³.

Early detection of CRC is recommended with the use of tumor markers. Recently, tumor markers for CRC that widely used are the carcinoembryonic antigen (CEA), carbohydrate antigen 19-9 (CA19-9), and Platelet to Lymphocyte Ratio (PLR)¹³.

Previous studies have been evaluating mRNA of different tumour genes in whole blood plasma or circulating tumour cells to identify new CRC screening markers. Most of them investigated mRNA molecules including CEA because this marker could be used as early detection and progress monitoring of CRC¹⁵^,¹⁶. CEA levels are also used as the initial detection of metastases because tumor cell metastases occur when CEA levels elevated¹⁶. CEA was first considered specific for CRC, but elevated CEA levels were later detected in other neoplasms such as gastric and pancreatic cancers. In addition, CEA elevation can be detected in inflammatory conditions¹⁷. The previous study showed the sensitivity of CEA ranged from 17.4 % to 100%, the specificity ranged from 66.1% to 98.4 %, the positive predictive value ranged from 45.8% to 95.2%, and the negative predictive value ranged from 74.5% to 100%¹⁸.

CA19-9 was initially detected in the tissues of the colorectal and current has been detected in the pancreas, stomach, and the epithelium of the biller. The specificity of CA 19-9 for detecting CRC is 96%, however, its sensitivity is only 23%¹⁹. Regardless the low sensitivity of CA-19-9, some studies remain suggested that CEA and CA19-9 together may be used as tumor marker for early detection of CRC²⁰. Aside of CEA and CA-19-9, PLR could potentially be used as CRC marker. Recently, many studies have proven that inflammation plays an essential role in various stages of tumor development, including tumor occurrence, development, malignant transformation, invasion, and metastases²¹. PLR score as an indicator of inflammation and immune response plays a prognostic role in different tumors²². As an indicator of inflammation, the PLR also has certain predictive effects on the prognosis of tumors, such as pancreatic cancer, lung cancer, liver cancer, ovarian cancer, and breast cancer²³. Since this marker is convenient and cost-effective, this blood-derived marker has been widely investigated as a useful prognostic factor in various solid cancers including CRC^24,25.

Early detection of CEA, CA19-9, and PLR conducted at the early-stage lesions can mitigate in morbidity and mortality in patients with CRC²⁶. Elevated CEA concentrations are only rarely identified in CRC stage I. Moreover, CEA does not differentiate benign versus malignant polyps. Recently, some studies have investigated the advantages of mRNA molecules encoding CEA for the detection of CRC, but the results were not superior to those of CEA¹⁷. In some studies, high CEA concentrations in patients with CRC stage Ⅱ and Ⅲ were found to be potentially indicative of more aggressive types of cancer²⁷. Several studies have assessed the relationship between CEA and CA19-9 with CRC and the value of the accuracy¹⁶. The majority of researchers arrived at the conclusion that CA 19-9 sensitivity is much inferior to that of CEA, and that elevated CA 19-9 levels is a poor prognostic factor^28–31. The PLR value also has almost the same accuracy as the tumor marker CA19-9, which is 68.89% for diagnosing malignancy in patients with pancreatic tumors³². However, research related to the value of the accuracy of CEA, CA19-9, and PLR as tumor markers on the respondents in Indonesia remains needed because the data is still limited^33–35. This study aims to assess the accuracy value and the relationship of CEA, CA19-9, and PLR levels with CRC stage, tumor location, and metastases stage.

METHODS:

Study Design:

This study was conducted in Gastroenterology-Hepatology Division, Department of Internal Medicine, Faculty of Medicine-Dr. Soetomo Teaching Hospital, Surabaya. A total of 499 CRC patients we retrieved from hospital medical records between 2018-2020. We analyzed only 50 complete data about CEA, 25 data of CA 19-9 and 202 data of PLR. Due to some sample did not have complete data information. This study has obtained ethical feasibility from the ethics committee of the Dr. Soetomo General Hospital, Surabaya, Indonesia (0179/KEPK/IV/2021).

Biomarker Measurement:

CEA, CA 19-9, and PLR were chosen as CRC tumor markers. The normal range of CEA was <5ng/mL ³⁶. CEA levels below 5ng/mL were defined as normal and equal to or above 5ng/mL was defined as increased levels. For CA19-9, It has a higher sensitivity (80% approx.) and specificity (90% approx.) with an upper limit of 37 U/mL cut-off value³⁷. The optimal cut-off level for PLR was 169.5³⁸. We used Chemiluminescent Enzyme Immunoassay (CLEIA) to quantify the tumor markers (LUMIPULSE L-FABP, Fujirebio Inc., Tokyo, Japan).

CRC staging classification:

One of the common systems used to stage bowel CRC was TNM as previously described³⁹. T stage describes the primary tumor, N stage describes whether cancer has spread to the lymph nodes and M means whether cancer has been found to have spread to distant organs or tissues⁴⁰. CRC is divided into 5 stages, stage 0 was Tis, N0, and M0. Stage I was T1, N0, M0 and T1, N1, M0. Stage II was T2-T3, N0-N1, M0 and any T, N2-N3, M0. Stage III was T3-T4, any N, and M0. Stage IV was any T, any N, and M1⁴¹. Metastases means the dissemination of the cancer cells from one organ to another which is not directly connected to the primary site⁴².

Statistical Analysis:

Correlation of biomarkers with the CRC stage was tested using the Spearman Correlation test. The correlation test output was expressed by the p value, the direction of correlation, and the correlation coefficient (r). The value of p<0.05 was stated to be statistically significant. Diagnostic tests of sensitivity, specificity, and accuracy were calculated and manually checking by a 2x2 cross-tabulation (contingency table) representing the finding of a diagnostic test when compared to the actual disease state. Receiver-operating characteristic (ROC) curves were constructed to calculate the best cutoff values, including the Area Under the Curve (AUC), sensitivity, specificity, and accuracy of each biomarker (CEA, CA 19-9, and PLR level) with CRC and tumor stage. All these analyses performed with SPSS 25 Mac OSX.

RESULTS:

A total 499 patients were diagnosed with CRC, consisted of 255 men and 244 women with a range age 17-88 years old. The majority of patients had no metastasis cases (308/499, 61.7%). Among 318 patients with CRC stages data, 137 patients had stage IV (63.7%). According on the TNM stage, the majority of patients had T4 stage (190/313/38.1%), and 163 patients (32.7%) had the N2 stage. Among 395 patients with the tumor location data, most of the CRC was located in recto-sigmoid (207/395, 52.4%). While, the fewest located in colon was transversum (26/395, 6.6%). There are 149 CEA, 78 CA 19-9, and 441 PLR data. After remove the redundant data, we analyzed 50 complete CEA data, 25 CA 19-9 data, and 202 PLR data. CEA rates by sex, age, tumor location, and stage are shown in Table 1. Elevated CEA serum levels were identified in 27 (54%) patients with the majority of patients being women (14/27, 60.9%) with an age range of 55-73 years (13/27, 50%). The increase in CRC patients in stage M0 and stage III was 18/27 (43.9%) and 13/27 (43.3%), respectively. 18 patients without organ metastases had elevated CEA levels 18/27 (43.9%).

Table 1. CEA level based on gender, age, tumor location, and staging

Variabel	CEA (N= 50)		p-value
Variabel	Normal N = 23 (46%)	Elevated N = 27 (54%)	p-value
Gender			0.379
Male	14 (51.9%)	13 (48.1%)
Female	9 (39.1%)	14 (60.9%)
Age			0.468
17-35	3 (60%)	2 (40%)
36-54	6 (33.3%)	12 (66.7%)
55-73	13 (50%)	13 (50%)
>73	1 (100%)	0 (0%)
Tumor Size			0.245
0	0 (0.0%)	1 (100%)
1	1 (50%)	1 (50%)
2	5 (83.3%)	1 (16.7%)
3	6 (46.2%)	7 (53.8%)
4	11 (39.3%)	17 (60.7%)
Nodes			0.799
0	7 (46.7%)	8 (53.3%)
1	6 (40%)	9 (60%)
2	10 (50%)	10 (50%)
3	0 (0%)	0 (0%)
Metastases stage			0.002*
0	23 (56.1%)	18 (43.9%)
1	0 (0%)	9 (100%)
CRC Stage			0.021*
0	0 (0%)	0 (0%)
I	1 (100%)	0 (0%)
II	5 (50%)	5 (50%)
III	17 (56.7%)	13 (43.3%)
IV	0 (0%)	9 (100%)
Tumor Location			0.136
Caecum	5 (55.6%)	4 (44.4%)
Ascenden	7 (58.3%)	5 (41.7%)
Transversum	2 (66.7%)	1 (33.7%)
Descenden	2 (50.0%)	2 (50.0%)
Rectosigmoid	7 (31.8%)	15 (68.2%)
Metastases Organ			0.002*
No Metastases	23 (54.8%)	18 (43.9%)
One Organ	0 (0%)	7 (100%)
Multi Organ	0 (0%)	2 (100%)

Figure 1. Receiver Operating Characteristic (ROC) curve for CEA with M Stage (a), CRC Stage (b), and Metastasis (c)

We found a significant correlation between CEA with M stage (p = 0.002, r = 0.432) and CRC stage (p = 0.021, r = 0.325), suggesting higher CEA levels are associated with increased metastasis stage, and cancer spread. There was 43.9% of non-metastases patients who had elevated CEA values. We also found a significant correlation between CEA scores and the number of metastases organs with moderate positive correlation power (p = 0.002, r = 0.431). In addition, the results of sensitivity, specificity, and accuracy of the M stage (Figure 1) were 33.3%, 100%, and 66.7%, respectively, (AUC = 0.667). Then, CEA was compared with CRC stage to 33.3%, 100%, and 66.5%, respectively (AUC = 0.665). We also compared CEA with organ metastases to be 33.3%, 100%, and 66.7%, respectively (AUC=0.667).

Table 2. CA 19-9 level based on gender, age, tumor location, and staging

Variable	CA-19 9 (N=25)		p-value
Variable	Normal N=15 (60%)	Elevated N=10 (40%)	p-value
Gender			0.533
Male	8 (66.7%)	4 (33.3%)
Female	7 (53.8%)	6 (46.2%)
Age			0.681
17-35	2 (66.7%)	1 (33.3%)
36-54	6 (66.7%)	3 (33.3%)
55-73	6 (50%)	6 (50%)
>73	1 (100%)	0 (0%)
Tumor Size			0.065
1	1 (100%)	0 (0%)
2	3 (100%)	0 (0%)
3	4 (66.7%)	2 (33.3%)
4	7 (46.7%)	8 (53.3%)
Nodes			0.112
0	4 (80%)	1 (20%)
1	8 (66.7%)	4 (33.3%)
2	3 (37.5%)	5 (62.5%)
Metastasis stage			0.023
0	15 (68.2%)	7 (31.8%)
1	0 (0%)	3 (100%)
CRC Stage			0.045
I	1 (100%)	0 (0%)
II	3 (75%)	1 (25%)
III	11 (64.7%)	6 (35.3%)
IV	0 (0%)	3 (100%)
Tumor Location			0.730
Caecum	2 (50%)	2 (50%)
Ascenden	3 (60%)	2 (40%)
Transversum	2 (100%)	0 (0%)
Descenden	2 (100%)	0 (0%)
Rectosigmoid	6 (50%)	6 (50%)
Metastasis Organ			0.000*
No Metastasis	15 (68.2%)	7 (31.8%)
One Organ	0 (0%)	3 (100%)
Multi Organ	0 (0%)	0 (0%)

CA 19-9 and CRC:

Table 2 showed the elevated of serum CA 19-9 levels were identified in 10 (40%) patients. Interestingly, all CRC patients at metastasis stage, stage IV, and single-organ metastasis had elevated CA 19-9 levels. There was a significant positive correlation between CA 19-9 and M stage (p = 0.023, r = 0.452), CRC stage (p = 0.045, r = 0.405), and metastasis organs (p = 0.023, r = 0.452).

Figure 2. Receiver Operating Characteristic (ROC) curve for CA 19-9 with M Stage (a), CRC Stage (b), and Metastasis Organ (c)

In stage M, the AUC CA 19-9 is 0.650 with sensitivity, specificity, and accuracy were 30%, 100%, 65%, respectively. Meanwhile, the staging of CRC was 30%, 100%, and 69.7%, respectively, with an AUC of 0.697. Last one, in organ metastasis were 30%, 100%, 65%, respectively with AUC 0.650 (Figure 2).

Table 3. PLR level based on gender, age, tumor location, and staging

Variabel	PLR (N=202)		p-value
Variabel	Normal N=82 (40.6%%)	Elevated N=120 (59.4%)	p-value
Gender			0.817
Male	41 (39.8%)	62 (60.2%)
Female	41 (41.4%)	58 (58.6%)
Age			0.719
17-35	9 (47.4%)	10 (52.6%)
36-54	31 (36%)	55 (64%)
55-73	38 (44.2%)	48 (55.8%)
>73	4 (36.4%)	7 (63.6%)
Tumor Size			0.200
0	5 (45.5%)	6 (54.5%)
1	0 (0%)	1 (100%)
2	7 (58.3%)	5 (41.7%)
3	21 (44.7%)	26 (55.3%)
4	49 (37.4%)	82 (62.6%)
Nodes			0.845
0	18 (38.3%)	29 (61.7%)
1	23 (46.9%)	26 (53.1%)
2	40 (38.1%)	65 (61.9%)
3	1 (100%)	0 (0%)
Metastasis stage			0.001*
0	62 (47.9%)	62 (52.1%)
1	20 (25.6%)	58 (74.4%)
CRC Stage			0.047*
0	3 (50%)	3 (50%)
I	2 (66.7%)	1 (33.3%)
II	12 (50%)	12 (50%)
III	41 (43.2%)	54 (56.8%)
IV	24 (32.4%)	50 (67.8%)
Tumor Location			0.185
Caecum	5 (23.8%)	16 (76.2%)
Ascenden	13 (38.2%)	21 (61.8%)
Transversum	3 (25%)	9 (75%)
Descenden	12 (57.1%)	9 (42.9%)
Rectosigmoid	48 (42.9%)	64 (57.1%)
Metastases Organ			0.003*
No Metastases	62 (50%)	62 (50%)
One Organ	12 (19.4%)	50 (80.6%)
Multi Organ	8 (50%)	8 (50%)

PLR and CRC:

Elevated PLR serum levels were identified in 120 patients (59.4%) (Table 3). Elevated PLR levels were shown in M0 stage (62, 52.1%) with (p = 0.001, r = 0.242), stage III of CRC patients (54, 56.8%) with (p = 0.047, r = 0.140), and in the no organ metastasis (62, 50%) with (p = 0.003, r = 0.206). The sensitivity, specificity, and accuracy of PLR compared to metastasis to be 48.3%, 75.6%, and 62% respectively (0.620), PLR compared to CRC stage to be 41.7%, 70.7%, and 57.6% respectively (0.576). Meanwhile, PLR compared with organ metastasis to be 48.3%, 75.6%, and 60.4% respectively (0.604) (Figure 3).

Figure 3. Receiver Operating Characteristic (ROC) curve for PLR with Colorectal Metastases stage (a), Cancer Stage (b), Metastases Organ (c).

DISCUSSION:

Patients with CRC metastasis were associated to higher CEA level⁴³. Similar results with this finding were found in a study in Japan, which consisted of 59 CRC patients with the result of positive correlation between positive CEA value and liver metastasis caused by CRC⁴⁴. Liver is the organ that primarily processes CEA. Majority of deaths caused by CRC are often linked with liver metastasis⁴⁵. Sensitive, specific, and accurate markers are needed for diagnosing and monitoring CRC. In this study, the sensitivity and accuracy of CEA was low for detection of M stage, CRC stage, and metastasis. However, the specificity was high for each of that. This results imply that CEA was not recommend to designate a patient with CRC positive or not, however, CEA can be used to designate an individual who does not have a CRC as a negative group. In the current study, the AUC of CEA compared with colorectal M stage and metastasis organ was higher than CRC stage (0.667). This indicated that CEA was more accurate to detect M stage and metastasis organ rather than CRC stage. Another study in China resulted in similar values for AUC, with the value of CEA is 0.681. This study implied that CEA and CA19-9 are commonly used as biomarkers for diagnosing CRC, yet they are not entirely satisfactory in managing the patients because of the lack of sufficient specificity and sensitivity⁴⁶.

CEA as a biomarker is not specific in determining the presence of CRC. CEA is a protein that exists in fetal gut tissue, yet by the time of birth, serum levels cannot be detected⁴⁷. This protein has been found in colorectal tumors patients and patients who have a variety of carcinomas (e.g., breast, pancreatic, gastric, hepatobiliary), sarcomas, and even many benign diseases (e.g., ulcerative colitis, diverticulitis, cirrhosis) ⁴⁸. Smaller and earlier-staged tumors are likely to have minimal CEA elevations, if not normal CEA levels. But there were many patients with advanced gastrointestinal tumors that may not have elevated CEA levels³⁵. CEA can also be detected in bodily fluids other than blood, as its presence in those bodily fluids indicates metastasis. This antigen is commonly measured in peritoneal fluid or chest effusions. An elevated CEA in these fluids indicates metastasis to the peritoneum or pleurae, respectively.⁴⁹

There were positive significant correlations between CA 19-9 with M stage and CRC stages in this study. In advanced stages of CRC, the value of CA 19-9 is raised ⁵⁰. Along with CEA, CA 19-9 is also a risk factor that might cause liver metastasis of CRC. By amplifying cell adhesion and promoting angiogenesis indirectly, CA 19-9 had a role in cancer invasion⁵¹. In this study, the sensitivity and accuracy of CA 19-9 in the detection of M stage, CRC stage, and metastasis organ was low. However, the specificity was high. Therefore, CA 19-9 is not recommended for determining whether a patient has CRC or not. Nevertheless, CA 19-9 can be a useful tool for identifying individuals without CRC, thus establishing a negative classification.

The AUC of CA19-9 compared with CRC stages was 0.697. Meanwhile, the AUC for CA 19-9 compared with M stage and metastasis organ was 0.650. The results showed that CA 19-9 was also more accurate to detect CRC stages rather than M stage and metastasis organ. Another study in China resulted in similar values for AUC, with the value of 0.651 for CA 19-9⁴⁶. The tumor marker CA 19-9 was discovered as a monoclonal antibody from mice injected with CRC cells. The CA 19-9 epitope is also normally present in the biliary tract. Thus, in the presence of biliary tract disease, CA 19-9 levels may also be elevated⁵². CA 19-9 also had similar limitations. CA 19-9 levels may also be elevated in pancreatic and ovarian cancer. Elevation of CA19-9 level was associated with presence of lymph node metastasis⁴⁹.

Another study was conducted in large Korean study, involving 70,940 asymptomatic subjects. Of these subjects, elevated CA 19-9 levels were found in 1,063 people (1.5%), but only 4 were ultimately diagnosed with pancreatic cancer. The results of this study showed that although the sensitivity and specificity of CA 19-9 were quite high (100% and 98.5%), the positive predictive value was only 0.9% in the asymptomatic population⁵³. Another study performed cancer detection by CEA and CA 19-9 examination in 202 subjects with gastrointestinal symptoms. In that study, the specificity of CEA and CA 19-9 were the same at 94%. Meanwhile, the sensitivity of CEA was 53% and CA 19-9 was only 29%⁵⁴.

The sensitivity, and accuracy of PLR in the detection of metastasis stage, CRC stage, and metastasis were low. However, the specificity remains more than 70% for all variables. These findings indicate that using PLR is not advisable for confirming whether a patient has CRC or not. However, PLR can be employed to classify individuals who do not have CRC as part of a negative group even though the results should be confirmed by another marker such as CEA and CA 19-9. PLR as the prognosis factor for survival prediction in tumors mainly had been studied in ovarian and pancreatic cancer and it was mainly correlated with Neutrophil to Lymphocyte Ratio (NLR). The prognostic value of PLR is directed mostly by platelet count and it might be reduced by the use of leukocytes⁵⁵. In this study, the analysis showed that PLR have any significances correlated with CRC stages and metastasis. This was in agreement with previous findings that shows PLR accurate to predict locally advanced rectal adenocarcinoma⁵⁶.

This study has potential limitations. In the beginning, this study was performed in a single teaching hospital. Next, the selection procedure from inclusion criteria might have influenced the results. Nevertheless, the results of this study were clear and can be used as reference to create a guidance for CRC detection, especially in Indonesia.

CONCLUSION:

CEA, CA 19-9 and PLR should not be relied upon to ascertain the presence of CRC in a patient, in the term of detection of M stage, CRC stage, and metastasis. However, they can serve as valuable tools in identifying individuals without CRC, enabling the establishment of a negative classification. When it comes to identifying CRC cases, CEA and CA 19-9 may be used as standalone markers, whereas PLR is best utilized in conjunction with another marker.

ACKNOWLEDGEMENT:

This study was supported by the Directorate of Research, Technology and Community Service, Ministry of Education, Culture, Research and Technology of the Republic of Indonesia and Joint Research SATU Presidents.

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Received on 22.11.2023 Revised on 20.12.2024

Accepted on 02.06.2025 Published on 08.11.2025

Available online from November 13, 2025

Research J. Pharmacy and Technology. 2025;18(11):5258-5266.

DOI: 10.52711/0974-360X.2025.00758

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