Diagnostic value of ultrasound indicators of neoplastic risk in preoperative differentiation of adnexal masses

Risk scores to guide referral decisions for people with suspected ovarian cancer in secondary care: a systematic review and cost-effectiveness analysis

BACKGROUND

Ovarian cancer is the sixth most common cancer in UK women and can be difficult to diagnose, particularly in the early stages. Risk-scoring can help to guide referral to specialist centres.

OBJECTIVES

To assess the clinical and cost-effectiveness of risk scores to guide referral decisions for women with suspected ovarian cancer in secondary care.

METHODS

Twenty-one databases, including MEDLINE and EMBASE, were searched from inception to November 2016. Review methods followed published guidelines. The meta-analysis using weighted averages and random-effects modelling was used to estimate summary sensitivity and specificity with 95% confidence intervals (CIs). The cost-effectiveness analysis considered the long-term costs and quality-adjusted life-years (QALYs) associated with different risk-scoring methods, and subsequent care pathways. Modelling comprised a decision tree and a Markov model. The decision tree was used to model short-term outcomes and the Markov model was used to estimate the long-term costs and QALYs associated with treatment and progression.

RESULTS

Fifty-one diagnostic cohort studies were included in the systematic review. The Risk of Ovarian Malignancy Algorithm (ROMA) score did not offer any advantage over the Risk of Malignancy Index 1 (RMI 1). Patients with borderline tumours or non-ovarian primaries appeared to account for disproportionately high numbers of false-negative, low-risk ROMA scores. (Confidential information has been removed.) To achieve similar levels of sensitivity to the Assessment of Different NEoplasias in the adneXa (ADNEX) model and the International Ovarian Tumour Analysis (IOTA) group's simple ultrasound rules, a very low RMI 1 decision threshold (25) would be needed; the summary sensitivity and specificity estimates for the RMI 1 at this threshold were 94.9% (95% CI 91.5% to 97.2%) and 51.1% (95% CI 47.0% to 55.2%), respectively. In the base-case analysis, RMI 1 (threshold of 250) was the least effective [16.926 life-years (LYs), 13.820 QALYs] and the second cheapest (£5669). The IOTA group's simple ultrasound rules (inconclusive, assumed to be malignant) were the cheapest (£5667) and the second most effective [16.954 LYs, 13.841 QALYs], dominating RMI 1. The ADNEX model (threshold of 10%), costing £5699, was the most effective (16.957 LYs, 13.843 QALYs), and compared with the IOTA group's simple ultrasound rules, resulted in an incremental cost-effectiveness ratio of £15,304 per QALY gained. At thresholds of up to £15,304 per QALY gained, the IOTA group's simple ultrasound rules are cost-effective; the ADNEX model (threshold of 10%) is cost-effective for higher thresholds.

LIMITATIONS

Information on the downstream clinical consequences of risk-scoring was limited.

CONCLUSIONS

Both the ADNEX model and the IOTA group's simple ultrasound rules may offer increased sensitivity relative to current practice (RMI 1); that is, more women with malignant tumours would be referred to a specialist multidisciplinary team, although more women with benign tumours would also be referred. The cost-effectiveness model supports prioritisation of sensitivity over specificity. Further research is needed on the clinical consequences of risk-scoring.

STUDY REGISTRATION

This study is registered as PROSPERO CRD42016053326.

FUNDING DETAILS

The National Institute for Health Research Health Technology Assessment programme.

Discriminative value of CA-125, HE4, Risk of Malignancy Index II (RMI-II) and Risk of Malignancy Algorithm (ROMA) in the differential diagnosis of pelvic masses: conclusions from a referral Centre in Portugal

The major purpose of this article was to compare the discriminative value of different algorithms and serum biomarkers in the differential diagnosis of adnexal masses. We performed a retrospective study with 247 women with adnexal neoplasia, submitted to surgical treatment and with a histological diagnosis. The evaluation of the area under the curve (AUC) for isolated CA-125 and HE4, and for ROMA and RMI-II, showed a better specificity of HE4 and RMI-II in premenopausal women. In the postmenopausal group, ROMA and RMI-II were the algorithms with a better performance. Impact Statement What is already known on this subject? CA-125 remains the most commonly used biomarker used to predict the behaviour of an adnexal mass, but it has a low sensitivity for stage I tumours. Other isolated serum markers have emerged more recently, such as HE4, as well as more complex algorithms, such as RMI or ROMA. It remains unclear which is the best marker/algorithm to predict the behaviour of an adnexal mass. What do the results of this study add? Our findings showed that ROMA is a suitable marker for postmenopausal women, with no advantage found in the premenopausal women when compared with an isolated HE4. What are the implications of these findings for clinical practice and/or further research? The different algorithms of the preoperative discrimination of ovarian neoplasia appear to have different AUC, SN and SP in the pre- or the postmenopausal patients. For the premenopausal women, the use of ROMA does not seem to have any advantage over the isolated use of HE4, which does not lose specificity even when the borderline tumours are considered for discrimination. In the postmenopausal women, ROMA is a valid algorithm with a good sensitivity. The RMI-II showed a good performance in both groups, although it depends on the ultrasound findings and has an important interobserver variability. This information allows a more targeted selection of markers and algorithms to be requested prior to surgery of ovarian neoplasms regarding the menopausal status of each patient.