**Abstract**

This study aimed to compare the non-acid nucleic blood multi-factor panels together and with mammography in terms of sensitivity, specificity, and accuracy in primary breast cancer detection (I, II, III, and IV). We systematically reviewed studies assessing non-acid nucleic blood tumor markers panels' diagnostic value in both healthy women and patients (before any anticancer treatment) for the detection of primary breast cancer. Out of the 2358 titles initially identified, 12 studies and 9 panels were included in the network meta-analysis. Panels I (MSA + B2m) and J (GATA3 + Ecadherin) had the highest sensitivity in all stages of primary breast cancer but had no significant difference with mammography. Panels L (MSA + CA15–3) and B (M-CSF- + CA15–3) had the highest specificity in all stages compared to other panels but no remarkable difference with mammography. Panels J (GATA3 + E-cadherin) and I (MSA + B2m) respectively had the highest accuracy in primary breast cancer detection but no considerable difference with mammography in terms of accuracy. Panel J, including GATA3 + E-cadherin, demonstrated a higher diagnostic value for primary breast cancer detection (I, II, III, and IV) than the rest of the panels.

**Keywords:** primary breast cancer, blood tumor markers, timely diagnosis, sensitivity and specificity, multi-factor panels, network meta-analysis

### **1. Introduction**

Based on our previous study [1], the necessity of a noninvasive, accessible, costeffective, and reliable method for breast cancer detection based on blood factors was proved. Furthermore, blood multi-factor panels can be the best choice for such a

method thanks to improving the sensitivity and specificity of cancer detection considerably compared to the individual state. In that study [1], we had determined the best non-acid nucleic blood multi-factor panels for breast cancer detection in early stages and locoregional breast cancer (I, II, and III). In this brief study, however, we compared the best non-acid nucleic blood multi-factor panels in primary breast cancer detection (I, II, III, and IV) by conducting a network meta-analysis. In fact, this study aimed to offer new insight into the diagnostic value of the best panels of non-acid nucleic blood tumor markers to detect primary breast cancer along all stages not only in early stages. The breast malignancy that emerges and can be diagnosed for the first time is named primary breast cancer, and if it recurs after primary treatment including surgery, chemotherapy, hormone therapy, and radiotherapy individually or collectively, it will be named secondary breast cancer [2]. Primary breast cancer comprises locoregional (I, II, III) and metastatic stages (IV) [3].

## **2. Materials and method**

The systematic reviews of the observational studies were conducted based on PRISMA guidelines (Preferred Reporting Items for Systematic Reviews and Meta-analysis) [4]. Eligibility criteria, search strategy (supplementary material 1 B), databases, study selection, data extraction, and statistical analysis conformed to our former study [1]. The difference is that, in this brief study, we systematically reviewed the studies that have simultaneously assessed several tumor markers in the form of a panel to diagnose and detect breast cancer in all stages of primary breast cancer (I, II, III, and IV).

**The included panels** were **B**: M-CSF + CA15–3, **C**: VEGF + CA15–3, **D**: VEGF + M-CSF + CA 15–3, **E**: VEGF+ M-CSF, **F**: p16+ c-MYC+ P53, **G**: CA15–3 + CEA, **I**: MSA + B2m, **J**: GATA3 + E-cadherin and **L**: MSA + CA15–3.

All these panels were made based on simultaneous measurement of two or three blood tumor markers in patients and healthy people using a compatible linear combination method [5]. Panels (B, C, D, E, F, G) were assessed in more than one study (multiple studies), and panels (I, J, L) were only assessed in one study (single study). We conducted direct and indirect paired comparisons of the sensitivity, specificity, and accuracy of the included blood tumor markers panels for diagnosing primary breast cancer in all stages. All the investigations were conducted in comparison to mammography (M) as the gold standard [6–8], like our previous study (**Figure 1**) [1].

### **3. Results and discussion**

#### **3.1 Study selection**

Study selection conformed to our former study [1]. However, in this brief study, among the 54 studies relevant to our research question which contained 86 unique blood tumor markers panels (supplementary material 2) conforming to our eligibility criteria, only 12 studies and 9 panels presented enough data for estimating sensitivity and specificity in all stages (I, II, III, and IV) of primary breast cancer and could be included in the systematic review and network meta-analysis. These 12 studies were similar in terms of pre-analytical procedures and analytical methods (**Table 1**).

All the included and excluded studies are presented in **Figure 2**.

*A Short Communication: Non-acid Nucleic Blood Multi-Factors Panels for Primary Breast… DOI: http://dx.doi.org/10.5772/intechopen.108803*

#### **Figure 1.**

*Multiple comparison of different panels for sensitivity. B: M-CSF + CA15–3, C: VEGF + CA15–3, D: VEGF + M-CSF + CA 15–3, E: VEGF+ M-CSF, F: p16+ c-MYC+ P53, G: CA15–3 + CEA, I: MSA + B2m, J: GATA3 + Ecadherin. L: MSA + CA15–3 M = mammography.*

Association between diagnosis of primary breast cancer and blood tumor markers panels:

Panels I (MSA + B2m) and J (GATA3 + E-cadherin) had the highest sensitivity in primary breast cancer but did not have noticeable differences with mammography. Panels G (CA15–3 + CEA) and F (p16+ c-MYC+ P53) had the lowest sensitivity than the rest of the panels and mammography as mammography exhibited a remarkably better function than them, with OR = 0.13 and 95% CL (0.04–0.46) and OR = 0.15 and 95% CL (0.04–0.52) (**Figure 3a**, **Table 2**). In diagnostic tests, sensitivity had a vital role in screening diseases [21]. As a result, we can claim that the panels which had the highest sensitivity can be promising diagnostic tests in primary breast cancer screening, which included panels I and J in all stages of primary breast cancer. Panels L (MSA + CA15–3) and B (M-CSF + CA15–3) had the highest specificity but did not have remarkable differences with mammography. Panels G (CA15–3 + CEA) and D (VEGF + M-CSF + CA 15–3) had the lowest specificity as mammography demonstrated a superior function in specificity, with OR = 0.06 and 95% CL (0.01–0.39) and OR = 0.06 and 95% CL (0.02–0.19) (**Figure 3b**, **Table 3**). Mammography had a better function in specificity than a large number of panels, since it exhibited the highest specificity after panel L with OR = 2.54 and 95% CL (0.1–177.46) in diagnosing


#### *Breast Cancer Updates*


*A Short Communication: Non-acid Nucleic Blood Multi-Factors Panels for Primary Breast… DOI: http://dx.doi.org/10.5772/intechopen.108803*


*The scoring system based on the CASP checklist (specified for diagnostic studies) was applied to all studies. Thespecificity,andofallstudieswereevaluatedinallstagesofprimarybreastcancer(I,II,III,*

 *and IV).*

 *sensitivity, accuracy \*Basedonlinearcombination (5).*

**Table 1.**

*Characteristics of articled included in network meta-analysis.* *A Short Communication: Non-acid Nucleic Blood Multi-Factors Panels for Primary Breast… DOI: http://dx.doi.org/10.5772/intechopen.108803*

#### **Figure 2.**

*Flow diagram of included and excluded articles. \*Although we sent emails to articles' authors to get their full texts, we did not receive any answers.*

primary breast cancer. Panels J (GATA3 + E-cadherin) and I (MSA + B2m) possessed the highest accuracy in primary breast cancer but did not show significant differences with mammography. Panel L (MSA + CA15–3) did not demonstrate considerable differences with panel I; therefore, we could consider them approximately similar regarding accuracy. Panels G (CA15–3 + CEA) and F (p16+ c-MYC+ P53) possessed the lowest accuracy in primary breast cancer as mammography exhibited a considerably superior function in accuracy, with OR = 0.15 and 95% CL (0.07–0.3) and OR = 0.37 and 95% CL (0.17–0.74) (**Figure 3c**, **Table 4**).

The best panels based on total function: **J: GATA3 + E-cadherin, I: MSA + B2m.**

In diagnosing primary breast cancer, panels J and I exhibited the highest accuracy and total function compared to other panels. Overall, we recommend panel J because it had an even better function in accuracy than panel I, despite being minor (**Table 1**) and its study had a larger sample size (200). Panel J was made of GATA3 and E-cadherin. GATA3 is a transcription factor that plays a crucial role in the development and progression of breast cancer and can reverse the epithelial-mesenchymal transition. It also regulates the proliferation, differentiation, and development of cells. E-cadherin is a member of the cadherin family mainly expressed in epithelial cells. E-cadherin mediates the adhesion of allogeneic epithelial cells and plays a key role in epithelial cell aggregation and adhesion. Studies have demonstrated that the expression of cadherin is closely related to the invasion of breast cancer [18].

#### **Figure 3.**

*Estimated rank probability of all panels' sensitivity, specificity, and accuracy*. *B: M-CSF + CA15–3, C: VEGF + CA15–3, D: VEGF + M-CSF + CA 15–3, E: VEGF+ M-CSF, F: p16+ c-MYC+ P53, G: CA15–3 + CEA, I: MSA + B2m, J: GATA3 + E-cadherin. L: MSA + CA15–3 M = mammography.*

#### **4. Conclusion**

In conclusion, panel J including GATA3 + E-cadherin with a sensitivity of 90 and specificity of 91.7 demonstrated a higher diagnostic value for primary breast cancer than the rest of the panels as it exhibited higher function in accuracy than mammography, with OR = 1.38 and 95% CL (0.42–4.41), although it was not remarkable. After


*A Short Communication: Non-acid Nucleic Blood Multi-Factors Panels for Primary Breast… DOI: http://dx.doi.org/10.5772/intechopen.108803*

*B: M-CSF + CA15–3, C: VEGF + CA15–3, D: VEGF + M-CSF + CA 15–3, E: VEGF+ M-CSF, F: p16+ c-MYC+ P53, G: CA15–3 + CEA, I: MSA + B2m, J: GATA3 + E-cadherin L: MSA + CA15–3 M = Mammography.*

#### **Table 2.**

*Relative effects and its 95% credible interval of all pairwise panels for sensitivity based on Bayesian network metaanalysis method.*



*B: M-CSF + CA15–3, C: VEGF + CA15–3, D: VEGF + M-CSF + CA 15–3, E: VEGF+ M-CSF, F: p16+ c-MYC+ P53, G: CA15–3 + CEA, I: MSA + B2m, J: GATA3 + E-cadherin L: MSA + CA15–3 M = Mammography.*

#### **Table 3.**

*Relative effects and its 95% credible interval of all pairwise panels for specificity based on Bayesian network metaanalysis method.*


*A Short Communication: Non-acid Nucleic Blood Multi-Factors Panels for Primary Breast… DOI: http://dx.doi.org/10.5772/intechopen.108803*


*B: M-CSF + CA15–3, C: VEGF + CA15–3, D: VEGF + M-CSF + CA 15–3, E: VEGF+ M-CSF, F: p16+ c-MYC+ P53, G: CA15–3 + CEA, I: MSA + B2m, J: GATA3 + E-cadherin L: MSA + CA15–3 M = Mammography.*

**Table 4.**

*Relative effects and its 95% credible interval of all pairwise panels for accuracy based on Bayesian network meta-analysis method.*

panel J, panel I (MSA + B2m) with a sensitivity of 90 and specificity of 90.3 and panel L (MSA + CA15–3) with a sensitivity of 84 and specificity of 100 had the best function in primary breast cancer detection than the rest of the panels. However, more experimental studies are required with larger samples, on different populations, and using other chemical measurement methods to verify these results.

#### **Acknowledgements**

This study was supported by Research Institute and Cancer Prevention Research Center, Isfahan University of Medical Sciences.
