INTRODUCTION:

Colorectal cancer (CRC) tumors affecting the colon, rectum, and appendix.¹ The incidence of CRC has steadily increased worldwide, especially in developing countries that adopt a "Western" lifestyle.² Indonesia, one of the developing countries, the standard incidence of CRC age per 100,000 population is 19.1 for men and 15.6 for women.³ It is the third most common cancer in Indonesia, and it is a new emerging health issue.

It is important to detect CRC as early as possible due to the worse prognosis would occur when it is late. The current standard test for diagnosing CRC is histopathological analysis using real-time diagnostic distal endoscopy including sigmoidoscopy and colonoscopy and biopsy.^4,5 Even after its many benefits, endoscopy is an invasive procedure that frequently causes distress in patients. In addition, the use of molecular diagnostic based on genetic and epigenetic methods has also been applied recently. However, it is relatively expensive. Therefore, both endoscopic and biomolecular examination has limited applicability in developing countries.

The success of CRC treatment is primarily influenced by early recognition of the diagnosis.⁶ However, there are several problems of early diagnosis in developing countries, including inadequate number expertise, endoscopic services that do not reach remote areas and expensive cost of examination. The tumor marker approach can be an alternative option for diagnosing early stage cancer safely, inexpensive and applicable that suitable for use in developing countries. In recent years, in addition to tumor tissues, lymph nodes, and bone marrow, the detection of biomarkers in tumor tissues can also be found in biological materials such as blood, urine, feces, and ascites. In developed countries the use of several colorectal cancer markers has been used in routine clinical practice, including carcinoembryonic antigen (CEA), carbohydrate antigen (CA 19-9), tissue polypeptide specific antigen (TPS) and tumor-associated glycoprotein-72 (TAG-72), circulating tumor DNA (ctDNA), insulin-like growth-factor binding protein 2 (IGFBP-2), hematopoietic growth factor and circulating tumor cell (CTC). However, various biomarkers have been introduced, but not yet their application has not been widely used especially in developing countries. The purpose of this review is to identify biomarkers which can be used for non-invasive blood-based markers for early detection of CRC diagnosis that suitable for use in developing countries.

Carcinoembryonic antigen (CEA):

CEA is indeed a carcinoembryonic protein antigen that is found in many epithelial tumors. It is responsible for the aggregation of CRC cells as adhesion molecules between cells. In the diagnosis of CRC, high CEA levels were found through 70%. High CEA levels in patients with stage tumors that have not metastasized to lymph nodes and tumors that have spread to nearby lymph nodes have been shown in some studies to potentially indicate more assertive kinds of cancer.⁷ Previously, the Colorectal Working Group of the American Joint Committee on Cancer recommended that classify the basal level of CEA in the TNM classification as stage C. Therefore, it is used as a marker of treatment and follow-up of patients undergoing curative resection therapy, recurrence and prognostic factor for CRC patients.^6,8

A low sensitive in early stage of CRC has been proven by a study showed that 67% CRC patients in stage I were detect normal CEA concentrations (≤5 ng/mL) .⁸ Although considered specific for CRC, elevated serum concentrations have also been detected in several conditions such as hepatitis, pancreatitis, inflammatory bowel disease and other non-colorectal malignancies.^6,9,10 A study showed that CEA has a high specificity of 88% (95% CI: 87 to 90), but a low sensitivity of 62% (95% CI: 59 to 66) in detecting CRC.¹¹ Therefore, the guidelines of the European Tumor Markers Group (EGTM), The European Society of Medical Oncology and the American Society of Clinical Oncology purposed the use of CEA in screening tests is not recommended.^12–15

CEA has a half-life of about 7 days since CRC surgical removal, and the CEA level should continue as normal in 4-6 weeks. A recent study showed that the combined use of CEA and serum amyloid A (SAA) can identify patients with good and poor prognosis. Recent research, on the other hand, has shown that CEA and CA 19-9 are useful predictors of Cetuximab's efficacy in combination with first-line chemotherapeutics. All such markers can also be used to evaluate Cetuximab resistance and as an early indicator of the influence of initial treatment.¹⁶. Thus, CEA is a reasonably practical examination. Although the CEA level is not always consistent with the stage and the degree of differentiation, CEA is adequate to see if the treatment of colorectal cancer is successful, based on the evaluation of postoperative CEA reduction, if there are differences in each stage of colorectal cancer.

CA 19-9

CA 19-9 is a heavy molecule whose presence can be measured in the bloodstream.⁶ CA 19-9 is a glycosylated extracellular protein MUC1 antigen which facilitates cancer incursion by raising cell attachment and indirectly enhancing cell proliferation. Although it is more widely recognized in treatment of patients with pancreatic cancer, 35% to 40% increment of CA 19-9 is observed in patients with advanced colorectal cancer.¹⁷ CA 19-9 is primarily produced by pancreatic, stomach, lung, cholangiocarcinoma, and colorectal cancers. Patients with cirrhosis, acute cholangitis, diabetes, endometriosis, or bronchiectasis, on the other hand, had raised CA 19-9 levels.

A study of patients with colorectal cancer carried out three consecutive measurements of the tumor markers CEA, CA19-9 and CEA & CA19-9. It showed that 7.3% of the cases had elevated concentration of CA 19-9 while CEA levels did not increase, and 55.4% with elevated levels of CA 199 and CEA.¹⁷ According to a review, CA 19-9 has a diagnostic sensitivity of 34% and a specificity of 55% in identifying CRC. Numerous research findings have also shown that CA 19-9 sensitivity is lower than CEA, and that high CA 19-9 levels are indeed associated with significant morbidity.^13,18,19 The use of CEA and CA 19-9 testing together, on the other hand, may enhance the diagnostic sensitivity of detecting CRC.^17,20 The method consisting of CEA, CA 19-9, CA 724, CA 242, and CYFRA211, on the other hand, enhances diagnostic accuracy as compared to using these biomarkers by itself.^21–24 A study also showed that adjuvant chemotherapy can only benefit patients with high CA 19-9 or high CA 19-9 and CEA.²⁵ Utilization of these biomarkers mostly for prognostic factor in the stage evaluation and survival rate.

CEA and CA19-9 levels were incredibly high in CRC found in the sigmoid region.²⁶ In contrast, CA 19-9 concentration and sensitivity rise with Dukes' disease stage, and therefore do not correlate with tumor site or the number of positive lymph nodes. Patients with Dukes' C tumors who had preoperative CA 19-9 levels greater than 37U/mL used to have a relatively short illness survival period.²⁷ Both these carbohydrate antigens, including CA 195 and CA 50, have also been studied, but with varying findings.²⁸ CA 72-4 provides verging substantial diagnostic data in recurrent CRC, even worse than CEA. Since it is unaffected by chemotherapy, CA 19-9 is a more stable tumor marker.¹⁷ As a result, we considered that CA 19-9 levels be measured in all patients with colorectal cancer.

TPS:

TPS is a dissolved fragment of a polypeptide chain that is produced in the molecular cycle of mitotic division originating from the terminal end of the carboxy cytokeratin which is released into the circulation. It can be used as diagnostic and chemotherapy monitor in several tumors such as colorectal, pancreatic, bronchial and ovarian tumors.^6,21,29 One study showed that approximately 75% of colorectal cancer patients have high levels of TPS antigen.³⁰ The cell division speed associated with cancer cell proliferation is closely related to the TPS level in the blood. Therefore, TPS is claimed to be particularly suitable for monitoring the treatment response because of it is more specific assessment of proliferation activity.³¹ A recent study showed that TPA is a useful tool for detecting CRC, as for specificity and sensitivity of 95% and 83%, in both.⁶ The majority of researchers discovered high concentrations of TPA as well as TPS during the metastases phase of CRC.⁷

In clinical practice, TPA also plays a role in prognostic factors. A study showed that patients with initially high TPS had lower survival rates.³⁰ Alterations through increased TPS concentrations occur to aid in determining treatment duration in symptomless individuals who received intensive treatment due to a bad prognosis. TPS concentrations must be routinely measured during treatment, mainly as just an indicator of non-response. As a result, TPS can perform better the commonly used CEA.

TAG-72:

Endothelial gastric epithelium, bile ducts and renal pelvic cells produce TAG-72, a glycoprotein. It has a molecular mass greater than 1000 kDa and is mucin-like. TAG-72 has been found on the surface of several tumor cells, including those from the colon, ovary, breast, and pancreas.³² In one study, 82% of the anti-TAG-72 B72.3 monoclonal antibody reacted to CRC.³³ In a study of 260 patients with benign and malignant CRC, estimated 40% had positive serum TAG-72 levels at the time of diagnosis.^34,35 TAG-72 has already been identified as a serum marker for CRC. The diagnostic sensitivity as a CRC marker ranges from 28% to 67%.³⁰ Another study also mentioned the diagnostic sensitivity and specificity were 40% and 77%, respectively.^10,36 Because of its low sensitivity, the application of TAG-72 alone in diagnostic screening was not applied in clinical setting. According to one research, serum levels of TAG-72, CEA, and CA 199 were increased in 43%, 43%, and 27% of colorectal cancer patients, respectively. When these three markers were measured, approximately 61% of patients had elevated levels of at least one marker.³⁷ As a consequence, it is recommended which TAG-72 be identified as a diagnostic marker for CRC alongside other markers (such as CEA and CA 199).

TAG-72 is considered a prognostic factor in CRC. A study in 578 patients regarding the association between the clinicopathological characteristics of CRC and the expression of tumors associated with TAG-72 showed that 24.9% were included in the TAG-72 overexpression group (TAG-72 high) in the univariate analysis (P = 0.001), the TAG-72 high group showing shorter disease-free survival.³⁸ Furthermore, TAG-72 is considered to be a factor throughout the development of CRC and might be a promising treatment.³⁸ Therefore, the use of TAG-72 in addition to being a diagnostic and prognostic factor may be considered as potential target for therapeutic of CRC patients.

ctDNA:

CtDNA is a DNA fragment found in non-cellular blood components of normal individuals. In various cancers, ctDNA is expected to be an excellent candidate for liquid biopsy in the future. CtDNA is a 150-200 base pair fragment released into the bloodstream by tumor cells, making up for a small proportion of the overall cfDNA. ctDNA is present in the blood through several sources, such as tumor cells apoptotic or necrotic, active tumor cells and circulating tumor cells.^39,40 The development of ctDNA as a blood-based fluid biopsy as a noninvasive test has growth rapidly due to its potential for CRC diagnostics, monitoring of therapeutic response and prognosis.⁴¹

According to a systematic review, methylated epigenetic ctDNA is by far the most potential candidate for blood CRC screening that use cell-free DNA (cfDNA).^41–43 Another 1493 participants were enrolled in a prospective cohort study in a large concentration found that the methylation marker cg10673833 had 89.7% of sensitivity (95% CI, 0.727 to 0.978) and 86.8% of specificity for performing CRC diagnostics (95% CI, 0.849 to 0.884).⁴⁴ A study in stage II and III used abnormal methylation of septin9 (mSEPT9) assay showed lower sensitivity 73.2%.⁴⁵ The distribution of cfDNA fragments in healthy individuals is regular, while in cancer patients it is irregular.^5,46 Despite of cancer, elevated plasma ctDNA levels have been observed in various medical conditions, including cancer, myocardial infarction, severe infection, inflammatory disease, and pregnancy.^47,48 Therefore, the use of ctDNA as an early diagnostic marker may be a good option.

ctDNA can also be used to identify and predict early recurrence. A study using ctDNA measurement method monitored tumor characteristics in surgical patients or chemotherapy patients using 162 plasma samples.⁴⁹ The risk classification of patients at high risk for CRC relapse can also be identified by ctDNA testing.⁵⁰ Patients with low risk CRC (T3N1), positive ctDNA levels after surgical resection, especially after 3 months of chemotherapy, indicate that treatment should be extended to 6 months.⁵¹ At the 2019 European Society for Medical Oncology (ESMO) conference, the IDEA-France Phase III clinical trial stimulated important conversation. ctDNA can guide individualized adjuvant chemotherapy therapy in high risk patients.^12,41 Furthermore, prospective standardization of DNA extraction and PCR technology methods will benefit reliable comparison of the results from various studies.⁴² Therefore, the application of ctDNA to postoperative monitoring fully reflects the concept of individualized precision medicine and is superior to traditional monitoring methods because it can identify recurrences earlier.

IGFBP-2:

IGFBP-2 is an extracellular protein which has a low affinity besides insulin-like growth factor-2 (IGF-2) and insulin-like growth factor-1 (IGF-1). IGFBP-2 plays a role in cancer invasion and metastasis mediated by family of proteins 27. Serum IGFBP-2 concentrations in patients with colon cancer were significantly elevated in reviewed groups.^11,52,53 The level of IGFBP-2 also seems to become a predictive marker which is mainly associated to survival rate.⁵⁴ It was discovered that IGFBP-2 is a determine possible and therapeutic biomarker for colorectal cancer, and also that the influence of IGF-II loss of imprinting (LOI) on CRC ability to survive is highly related to prognosis in patients with advanced disease.⁵⁵

The role of IGFBP2 in the carcinogenesis of CRC remains controversial. Increased expression of IGFBP2 has been discovered in invasive ovarian, breast and colorectal cancer.^55–58 IGFBP2 overexpression prevent the development of colorectal adenomas prior to the appearance of CRC, according to studies with transgenic mouse animal models.⁵⁹ In an epidemiological study, having a higher level of serum IGFBP2 even before onset of cancer is correlated with significantly lower risk of colon cancer.⁶⁰ Even though predictive value of IGFBP2 for the risk of CRC interesting question, the significant increase in IGFBP2 during cancer diagnosis and the analysis of this research recommend that IGFBP2 might be a CRC standardized instruments In clinical trials, seeing as 4,444 subjects with high plasma IGFBP2 levels seem to be more highly probable to have CRC and they should be screened for CRC with a colonoscopy.⁵⁵ Whereas, the disadvantage of sensitivity and specificity for early CRC and colon polyps. As a consequence, further research into the accuracy of IGFBP2 associated with other biomarkers in identifying possible CRC is warranted.

Hematopoietic growth factor:

Cancer growth and spread are controlled by hematopoietic growth factors.⁶ Colorectal cancer cells produce hematopoietic cytokines on their own. Members of the group recognized as hematopoietic growth factor (HGF) or colony stimulating factor (CSF) involve stem cell factor (SCF), interleukin 3 (IL3), granulocyte macrophage colony stimulating factor (GMCSF), and macrophage colony stimulating factor (MCSF).^61–63 HGF regulates hematopoietic progenitor cell proliferation and could also impact non-hematopoietic cell proliferation.⁶⁴ HGF has been shown in numerous studies to stimulate non-hematopoietic cell proliferation, and cytokines have an effect on cells apart from bone marrow.^63,64 To accelerate cancer growth, cytokines may act autocrine on cancer cells or paracrine on supporting tissues such as fibroblast cells and blood vessels. Normal cells, endothelial cells and tumor-associated macrophages (TAM), can also be triggered to generate more cytokines that aid the cancerous process.^63,65 Cytokines also can start regulating mechanisms involved in tumor progression, like angiogenesis and metalloproteinase development.⁶⁶

Several cancerous tumor cells were shown to metabolize massive volumes of HGFs. At higher concentrations, HGFs such as GM-CSF, G-CSF, and M-CSF were detected throughout the serum of patients with colorectal cancer.^62,67 Many other studies have also discovered the blood level of M-CSF as well as G-CSF in colorectal cancer patients were considerably higher than those in controls.^36,67 Both markers' levels were influenced by tumor stage, and yet only M-CSF showed substantial differences. Furthermore, patients with lymph node or distant metastases had greater M-CSF blood levels, suggesting that M-CSF may perform an usable role in tumor growth to metastasis, as reported earlier in animal studies.^65,67 As a result, M-CSF appears to become a more reliable sensitive predictor compared to G-CSF in the diagnosing of CRC. It indicates that M-CSF may be clinically effective, particularly in tumor diagnosis and staging.

CTC:

The most leading cause of death in colorectal cancer is partly related to distant metastases.⁶⁸ The association of progressive and metastasis is closely associated with the presence of CTC in the blood.¹⁰ Patients with low CTC concentrations have improved median progression-free and overall survival rates unlike individuals with high CTC concentrations.⁶⁹ Some other benefit of identifying CTCs is that it is included to monitor aggressive form disease who may not have remnants of many other surveillance indicators in their blood, along with CEA.¹⁰ As a consequence, CTC has also been recognized like an independent predictor of as a whole and survival in CRC.

CTC has benefits including to control the therapeutic response of CRC patients, to molecularly characterize captured CTCs in order to target them for treatment, and to cultivate captured CTCs for drug sensitivity testing. Each one of these techniques helps investigators to recognize as well as adjust to different throughout the phenotype of cancerous cells as the disease progresses, allowing personalized medicine to be implemented in clinical practice.¹¹ Many studies have described CTCs' role as prognostic markers in primary colorectal cancer.^70,71 Even after impressive outcomes, decisions regarding stage of disease and adjuvant treatment are still made without taking CTC performance into consideration ⁷².

The US Food and Drug Administration (FDA) authorized the CellSearchTM system (Veridex LCC, Raritan, NJ, USA) in 2008 even as diagnostic technique besides assessing and measuring CTCs in samples taken from CRC patients.^6,10 The FDA-accepted CellSearchTM system and CTC are detected using cytokeratin antibody test: cytokeratin 19, 8, and 18 (CK 19/8/18) and CK8/18/19/20. Cytokeratin 20 (CK) is a marker of mature colonic epithelial cells.⁶ Science investigation might indeed shed light on other medical practices for CTC as an important predictor, predictive, and surveillance indicator to aid clinicians in making determinations, forecasting metastases, and monitoring disease relapse.

Biomarkers for developing countries: which are suitable?

The term "biomarker" is frequently used to refer to a protein detected in blood whose level indicates the presence or severity of a certain disease state ⁷³. There was countless effort to establish blood markers for the early diagnosis of CRC.⁷⁴ Blood biomarkers are possible targets for non-invasive CRC detection and may assist in the early detection of the disease.⁷⁵ A study evaluated individual CRC diagnostic sample rates found that 78% of survey participants would like to receive blood samples.^76,77 Therefore, given that blood-based testing is extremely less invasive and can be easily performed in routine medical examinations, it may improve the suitability of population-based testing programs.⁷⁸ Blood in CRC patients contains a number of analytes, including CEA, CA 19-9,TPS, (TAG-72), ctDNA, IGFBP-2, hematopoietic growth factor and CTC.^1,21,30 They can be used to identify relapse as well as reaction to treatment. Numerous studies provided evidence of trying to cut data on numerous circulatory markers for identification, diagnosis, and survival rate.^10,32 There are several CRC early detection options. One of those, it is obvious that nanoparticles will be a common and well-liked occurrence in the future given their immense qualities and growing application in cancer diagnosis and treatment ⁷⁹. Furthermore, most early detections should not be forgotten, especially in developing countries, which are dominated by low-income countries and limited expertise. In an ideal early detection study, it is highly sensitive, specific, safe, useful, and convenient.^1,80 In summary, single biomarker assessment in early diagnosis is not relevant, which is generally due to inadequate sensitivity and specificity in clinical settings. ⁷⁵ TPS sensitivity appear to be useful for early diagnostic and it is superior to another biomarkers. However, the specificity is low. Hematopoietic growth factor with high specificity among all but low sensitivity (Table 1). According out observations, this review highlights the potential use of the combination of TPS and hematopoietic cells in the early detection of CRC in developing countries. To evaluate the sensitivity and specificity of all these blood biomarkers, large prospective studies are needed. Furthermore, future studies should focus on not only the statistical completion of different biomarkers, but also on the features and expense of comprehensive early detection programs in developing countries.

Table 1. Non-invasive tumor markers in the clinical diagnosis of colorectal cancer

Group/Markers	Source	Detection methods	Application in the management of CRC	Elevated values apart from CRC	Sensitivity	Specificity
Tumor antigen
CEA ^11,30,81	Serum samples	Enzyme-linked immunosorbent assays (ELISA) ⁸²	A sign of recurrence following tumor resection	Breast cancer, obstructive pulmonary disease and inflammation: liver, intestines and pancreas	64%	90%
CA 19-9 ^6,30,81	Serum samples	Radioimmunoassay (RIA) or ELISA ⁸³	Prognostic factor for tumor severity and overall survival	Pancreatitis, gastric tumor and pancreatic tumor	34%	55%
TPS ^6,29	Serum samples	Chemiluminescence immunoassay (CLIA) ⁸⁴	Response factor in monitoring chemotherapy; predict the growth of the tumor	Pancreatic and bronchial tumor	95%	83%
TAG-72 ^37,38	Serum samples; tissue biopsies	ELISA ^37,85	Diagnostic, prognostic and therapeutic target	Cholangitis and gastritis	40%; 28-47%	77%
ctDNA^41,44	Plasma of peripheral blood; liquid biopsy	Polymerase chain reaction (PCR) ^44,86,87	Diagnostic in early stage, monitoring post-operative recurrence; monitoring treatment response; monitoring therapeutic resistance	Myocardial infarction, severe infection, inflammatory diseases, and pregnancy	73.2%;89.7%	86.8%;86.8%
IGFBP-2 ⁵⁵	Serum samples	ELISA ⁸⁸	A prognostic and predictive variable that has a strong influence on survival rate	invasive ovarian carcinoma and breast cancer	80.2%	64%
Hematopoietic growth factor	Serum samples; cancer tissue samples		Regulation of growth and metastases of cancer
G-CSF^6,63		ELISA ⁶⁷		Gastric carcinoma	31%	95%
M-CSF ^6,64				Bone and tissues sarcoma, lung cancer	65%	95%
CTC^6,72	Serum samples	PCR ⁷²	Monitoring of the treatment; molecular characterization for targeted treatment; cultivation for drug sensitivity testing	Ovarian cancer	No data	No data

CONCLUSION:

A combined set of blood-based CRC biomarkers of TPS and hematopoietic growth factor appear to be more sensitive and specific to the detection method in the early stages of CRC in developing countries, which are less invasive and lead to patient decision-making, resulting in direct benefits for CRC patients.

ACKNOWLEDGMENT:

This study was supported by Penelitian Dasar Unggulan Perguruan Tinggi (PDUPT) Tahun 2020 (576/UN3.14/PT/2020), a grant from Universitas Airlangga, Surabaya, Indonesia.

CONFLICT OF INTEREST:

The authors declare no potential conflicts of interests.

AUTHOR CONTRIBUTIONS:

Conceptualization, YAAR, YY, MM; data acquisition, YAAR, SS, RI; data analysis and interpretation, IM, ED, LAW; writing—original draft preparation, YAAR, IM, ED; writing—review and editing, SS, LAW, RI, YY, MM. All authors have read and agreed to the published version of the manuscript.

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Received on 13.10.2022 Revised on 14.02.2024

Accepted on 01.11.2024 Published on 05.09.2025

Available online from September 08, 2025

Research J. Pharmacy and Technology. 2025;18(9):4527-4535.

DOI: 10.52711/0974-360X.2025.00650

This work is licensed under a Creative Commons Attribution-NonCommercial-ShareAlike 4.0 International License. Creative Commons License.

The Suitable Biomarkers of Colorectal Cancer for Developing Countries