The term epithelial ovarian cancer collectively includes high-grade serous epithelial ovarian, fallopian tubal, and peritoneal carcinomas due to their shared pathogenesis, clinical presentation, and treatment. We use epithelial ovarian cancer to refer to this group of malignancies in the discussion that follows. There is currently no serum biomarker that can distinguish between these types of carcinoma. An estimated 22440 women in the U. S. are expected to be diagnosed in 2017 with ovarian cancer, and approximately 14080 will die of the disease.^1, The mortality rate depends on three variables: (1) patient characteristics; (2) tumor biology (grade, stage, type); and (3) treatment quality (nature of staging, surgery, and chemotherapy used).^2, In particular, comprehensive staging and completeness of tumor resection appear to have a positive impact on patient outcomes.

In 1997, the Society of Surgical Oncology recommended ovarian cancer surgery and follow-up treatment be performed by physicians with ovarian cancer disease expertise.^3, Numerous articles have been published on the application of this recommendation examining long- and short-term outcomes as well as process measures (e.g., types of treatment such as complete staging or tumor debulking). At least two meta-analyses have concluded that outcomes are improved when patients with ovarian cancer are treated by gynecologic oncologists.^4,5, The available data are most convincing for patients with advanced-stage disease.

Adult women presenting with an adnexal mass have an estimated 68% likelihood of having a benign lesion.^6, About 6% of women with masses have borderline tumors; 22% possess invasive malignant lesions, and 3% have metastatic disease. Surgery is the only way to diagnose ovarian cancer; this is because a biopsy of an ovary with suspected ovarian cancer is usually not performed due to the risk of spreading cancer cells. Most clinicians agree that women with masses that have a high likelihood of malignancy should undergo surgical staging by a gynecologic oncologist. However, women with clearly benign masses do not require a referral to see a specialist. Therefore, criteria and tests that help differentiate benign from malignant pelvic masses are desirable.

In 2005, the American College of Obstetricians and Gynecologists and the Society of Gynecologic Oncologists jointly released referral guidelines that addressed criteria for referring women with pelvic masses suspicious for ovarian cancer to gynecologic oncologists.^7, Separate criteria were developed for premenopausal and postmenopausal women. In premenopausal women, referral criteria included at least one of the following: elevated cancer antigen 125 (CA 125; >200 U/mL), ascites, evidence of abdominal or distant metastasis, or positive family history. The referral criteria for postmenopausal women were similar, except that a lower threshold for an elevated CA 125 test was used (35 U/mL); moreover, a nodular or fixed pelvic mass was an added criterion.

Three multimarker serum-based tests specific to ovarian cancer have been cleared by the Food and Drug Administration (FDA) with the intended use of triaging patients with adnexal masses (see Regulatory Status section). They are summarized in Table 1. The proposed use of the tests is to identify women with a substantial likelihood of malignant disease who may benefit from referral to a gynecologic oncology specialist. Patients with positive results may be considered candidates for referral to a gynecologic oncologist for treatment. The tests have been developed and evaluated only in patients with adnexal masses and planned surgeries. Other potential uses, such as selecting patients to have surgery, screening asymptomatic patients, and monitoring treatment, have not been investigated. Furthermore, the tests are not intended to be used as stand-alone tests, but in conjunction with clinical assessment.

Other multimarker panels and longitudinal screening algorithms are under development; however, these are not yet commercially available.^8,9,

Table 1. Summary of FDA-Cleared Multimarker Serum-Based Tests Specific to Ovarian Cancer

Variables	OVA1	Overa	ROMA
Cleared	2009	2016	2011
Manufacturer	Quest Diagnostics	Vermillion	Roche Diagnostics
Biomarkers used
CA 125 II	X	X	X
b2-microglobulin	X
Transferrin	X	X
Transthyretin	X
Apolipoprotein AI	X	X
HE4		X	X
FSH		X
Score range	0-10	0-10	0-10
Risk categorization
Premenopausal	<5.0: low ≥5.0: high	<5.0: low ≥5.0: high	≥1.3: high
Postmenopausal	<4.4: low ≥4.4: high		≥2.77: high

CA 125: cancer antigen 125; FDA: Food and Drug Administration; FSH: follicle-stimulating hormone; HE4: human epididymis secretory protein 4.

Regulatory Status

In July 2009, the OVA1® test (Aspira Labs [Austin, TX]) was cleared for marketing by the FDA through the 510(k) process. OVA1® was designed as a tool to further assess the likelihood that malignancy is present when the physician’s independent clinical and radiologic evaluation does not indicate malignancy.

In September 2011, the Risk of Ovarian Malignancy Algorithm (ROMA™ test; Fujirebio Diagnostics [Sequin, TX]) was cleared for marketing by the FDA through the 510(k) process. The intended use of ROMA™ is as an aid, in conjunction with clinical assessment, in assessing whether a premenopausal or postmenopausal woman who presents with an ovarian adnexal mass is at a high or low likelihood of finding malignancy on surgery.

In March 2016, a second-generation test called Overa™ (also referred as next-generation OVA1®), in which 2 of the 5 biomarkers in OVA1® are replaced with human epididymis secretory protein 4 and follicle-stimulating hormone, was cleared for marketing by the FDA through the 510(k) process. Similar to OVA1®, Overa™ generates a low- or high-risk of malignancy on a scale from 0 to 10.

Black Box Warning

In December 2011, the FDA amended its regulation for classifying ovarian adnexal mass assessment score test systems. The change required that off-label risks be highlighted using a black box warning. The warning is intended to mitigate the risk to health associated with off-label use as a screening test, stand-alone diagnostic test, or as a test to determine whether to proceed with surgery. Considering the history and currently unmet medical needs for ovarian cancer testing, the FDA concluded that there is a risk of off-label use of this device.^10, To address this risk, the FDA requires that manufacturers provide notice concerning the risks of off-label uses in the labeling, advertising, and promotional material of ovarian adnexal mass assessment score test systems. Manufacturers must address the following risks:

• Women without adnexal pelvic masses (i.e., for cancer "screening") are not part of the intended use population for the ovarian adnexal mass assessment score test systems. Public health risks associated with false-positive results for ovarian cancer screening tests are well described in the medical literature and include morbidity or mortality associated with unneeded testing and surgery. The risk from false-negative screening results also includes morbidity and mortality due to failure to detect and treat ovarian malignancy.
• Analogous risks, adjusted for prevalence and types of disease, arise if test results are used to determine the need for surgery in patients who are known to have ovarian adnexal masses.
• If used outside the "OR" rule that is described in this special control guidance, results from ovarian adnexal mass assessment score test systems pose a risk for morbidity and mortality due to nonreferral for oncologic evaluation and treatment.

• Serum Biomarker Human Epididymis Protein 4 (HE4) (Policy #049 in the Pathology Section)

All uses of the OVA1, Overa, and ROMA tests are considered investigational including, but not limited to:

a. preoperative evaluation of adnexal masses to triage for malignancy, or
b. screening for ovarian cancer, or
c. selecting members for surgery for an adnexal mass, or
d. evaluation of members with clinical or radiologic evidence of malignancy, or
e. evaluation of members with nonspecific signs or symptoms suggesting possible malignancy, or
f. post-operative testing and monitoring to assess surgical outcome and/or to detect recurrent malignant disease following treatment.

1. Over age 18;
2. Ovarian adnexal mass present for which surgery is planned; and,
3. Not yet referred to an oncologist.

· Are over 18 years of age
· Have an ovarian mass
· Have surgery planned

Evidence reviews assess whether a medical test is clinically useful. A useful test provides information to make a clinical management decision that improves the net health outcome. That is, the balance of benefits and harms is better when the test is used to manage the condition than when another test or no test is used to manage the condition.

The first step in assessing a medical test is to formulate the clinical context and purpose of the test. The test must be technically reliable, clinically valid, and clinically useful for that purpose. The following is a summary of the key findings to date.

Multimarker Serum Testing Related to Ovarian Cancer

Clinical Context and Test Purpose

The purpose of multimarker serum testing of individuals over age 18 with an ovarian adnexal mass for which surgery is planned and not yet referred to an oncologist is to use the test as an aid to further assess the probability that malignancy is present, even when the physician’s independent clinical and radiologic evaluation does not indicate malignancy.

The questions addressed in this policy are: (1) Is there evidence that multimarker serum testing of individuals described above has clinical validity?; and (2) Does multimarker serum testing of such individuals change patient management in a way that improves outcomes as a result of testing?

The following PICOs were used to select literature to inform this policy.

Patients

The relevant population of interest are individuals who:

• Are over age 18
• Have ovarian adnexal mass for which surgery is planned
• Have not yet been referred to an oncologist
• A physician’s independent clinical and radiologic evaluation does not indicate malignancy.

The relevant interventions are three Food and Drug Administration (FDA)-cleared commercial multimarker serum genetic tests (e.g., OVA1, Overa, ROMA).Multimarker serum testing for related to ovarian cancer may be performed at any point when an individual presents with an ovarian adnexal mass for which surgery is planned, to use in conjunction with physician’s independent clinical and radiologic evaluation to assess the probability that malignancy is present and aid in the decision of whether a referral to an oncologist is indicated. Most patients are likely to be tested in an outpatient setting.

Comparators

The comparator of interest is a standard clinical assessment.

Outcomes

The potential beneficial outcomes of primary interest in the case of a true-negative would be the avoidance of unnecessary surgery and its associated consequences (e.g., morbidity, mortality, resource utilization, patient anxiety). The potential harms from a false-positive could be inappropriate assessment and improper management of patients with ovarian malignancies, which could result in the following: inappropriate surgical decisions, high frequency of unnecessary further testing, and unnecessary patient anxiety. The potential harms from a false-negative could be a determination that the patient does not have ovarian malignancy, which would lead to a delay in surgery and tumor diagnosis.

Off-label use of the test (e.g., in patients who have not already been identified as needing surgery for pelvic mass, or patients without reference to an independent clinical and radiologic evaluation), might lead to a high frequency of unnecessary testing and surgery due to false-positive results, or to a delay in tumor diagnosis due to false-negative results.

Study Selection Criteria

Below are selection criteria for studies to assess whether a test is clinically valid.

1. The study population represents the population of interest. Eligibility and selection are described.
2. The test is compared with a credible reference standard.
3. If the test is intended to replace or be an adjunct to an existing test; it should also be compared with that test.
4. Studies should report sensitivity, specificity, and predictive values. Studies that completely report true- and false-positive results are ideal. Studies reporting other measures (e.g., receiver operating characteristic , area under receiver operating characteristic, c-statistic, likelihood ratios) may be included but are less informative.
5. Studies should also report reclassification of the diagnostic or risk category.

Clinically Valid

A test must detect the presence or absence of a condition, the risk of developing a condition in the future, or treatment response (beneficial or adverse).

OVA1 Test

Descriptions of the developmental process for the OVA1 test have been published in the FDA documents and in a perspective by Fung (2010).^11,12, Candidate biomarkers were selected based on initial studies using mass spectroscopy but were converted to standard immunoassays to improve analytic performance. Seven final markers were evaluated, none of which individually appeared to be highly specific for the malignant ovarian disease. However, the choice of 5 of these (CA 125, prealbumin, apo AI, b₂-microglobulin, transferrin) produced a composite profile that did appear to have the discriminatory ability. The test, as cleared by the FDA, is performed on a blood sample, which is sent to a reference laboratory for testing using the five immunoassays previously described. Results of the five determinations are entered manually into an Excel spreadsheet used by the OvaCalc software. This software contains an algorithm that combines the five discrete values into a single unitless numeric score from 0.0 to 10.0.

Details of the algorithm appear proprietary, but the development is described as an empirical process; it is a process based on several different factors: the use of banked samples from academic partners; a small prospective study of samples from Europe; and a designated subset of samples from the clinical study used to support the submission to the FDA. It appears that at an undisclosed point in the developmental process-as a result of interaction with the FDA¾separate cut points were developed for premenopausal and postmenopausal women.

The clinical validity was evaluated in a prospective, double-blind, clinical study using 27 enrollment sites.^11, The study was supported by the commercial sponsor of the test. Patients underwent a complete clinical evaluation before surgical intervention, and only patients with adnexal masses who had a planned surgical intervention were included. The study enrolled 743 patients, with 146 subjects used in the training set and 516 in the testing set. Seventy-four patients were excluded because of missing information or samples. The final prevalence of cancer in the population was 27%.

Using pathologic diagnosis as the criterion standard, OVA1 test performance, when combined with a clinical assessment by nongynecologic oncologists, was as follows (see Table 2). The method used for combining clinical assessment and OVA1 results was to consider the test positive if either clinical assessment or OVA1 test was positive. Thus, in practice, OVA1 testing would not be necessary if clinical assessment alone indicated cancer. Using OVA1 testing in this manner guarantees that OVA1 testing will be more sensitive and less specific than clinical assessment alone, even if it has no better than the chance capability of detecting ovarian cancer. Sensitivity improved from 72% to 92%, and specificity decreased from 83% to 42%.

Table 2. Clinical Validity of the OVA1 Test^a Among 269 Patients Evaluated by Nongynecologic Oncologists

Diagnostic Characteristics	Clinical Assessment Alone, %	Clinical Assessment With OVA1 Test, %
Sensitivity	72	92
Specificity	83	42
Positive predictive value	61	37
Negative predictive value	89	93

Adapted from the FDA. 510(k) Substantial Equivalence Determination Decision Summary: OVA1™ Test (K081754) n.d.; http://www.accessdata.fda.gov/cdrh_docs/reviews/K081754.pdf. Accessed October 29, 2019
^a Confidence intervals not provided.

One additional study (by Grenache et al [2015]) was identified; it evaluated the diagnostic performance of the OVA1 test.^13, However, it did not evaluate diagnostic performance in conjunction with clinical assessment, as the test was intended to be used. By itself, OVA1 was 97% sensitive and 55% specific. This means that with clinical assessment (as intended to be used), the test would be no worse than 97% sensitive and no better than 55% specific, but these characteristics cannot be determined from the study.

Table 3. Summary of Key Study Characteristics

Study; Trial	Countries	Sites	Dates	Participants	Interventions
					Active	Comparator
Grenache (2015)	U.S.		2009 - 2011	Women with an adnexal mass (n=146)	OVA1	ROMA

Table 4. Summary of Key Study Results

Study	Sensitivity (95% CI)	Specificity (95% CI)	PPV (95% CI)	NPV (95% CI)
Grenache (2015)
OVA1	96.8% (83.3-99.9)	54.8% (45.2-64.1)	36.6% (26.2-48.0)	98.4% (91.6-99.9)
ROMA	83.9% (66.3-94.6)	83.5% (75.4-89.8)	57.8% (42.2-72.3)	95.1% (88.8-98.4)

CI: confidence interval; PPV: positive predictive value; NPV: negative predictive value.

The purpose of the limitations tables (see Tables 5 and 6) is to display notable limitations identified in each study. This information is synthesized as a summary of the body of evidence following each table and provides the conclusions on the sufficiency of the evidence supporting the position statement.

Table 5. Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Follow-Upe
FDA(k) OVA1 Test K081754	1. Some patients were not evaluated by a gynecologic oncologist; 3. Unclear how patients were recruited; 4. Enrollment was limited to patients with planned surgical intervention
Grenache et al (2015)	1. Patients were not evaluated by a gynecologic oncologist; 4. Enrollment included only patients with planned surgical intervention, due to the small number of women with malignant adnexal masses, the strength of conclusions was limited

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.
FDA: Food and Drug Administration.

^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4. Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

^a Selection key: 1. Selection not described; 2. Selection not random or consecutive (i.e., convenience).
^b Blinding key: 1. Not blinded to results of reference or other comparator tests.
^c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.
^d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.
^f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Descriptions of the developmental process for the Overa test have been published in FDA documents.^14,The FDA documents do not provide details on how biomarkers were selected. The test, as cleared by the FDA, is performed on a blood sample, which is to be sent to a reference laboratory for testing using the five immunoassays previously described. Results of the five determinations are entered into a proprietary algorithm, called OvaCalc software (v4.0.0), which combines the five discrete values into a single unitless numeric score from 0.0 to 10.0.

Clinical validity was evaluated in a nonconcurrent prospective study of 493 preoperatively collected serum specimens from premenopausal and postmenopausal women presenting with an adnexal mass requiring surgical intervention.^14, Overa test scores were determined based on the analysis of archived serum specimens from a previous study,^15, and the patient was stratified into a low- or high-risk group for finding malignancy on surgery. The analysis examined whether patient referral to a gynecologic oncologist was supported when adual assessment was determined to be positive (either Overa or clinical assessment was positive, or both were positive). A dual assessment was considered negative when both Overa and clinical assessment were negative.

Using pathologic diagnosis as the criterion standard, Overa test performance, when combined with clinical assessment by nongynecologic oncologists, was as follows (see Table 7). The method used for combining clinical assessment and Overa test results was to consider the test positive if either clinical assessment or Overa test was positive. Thus, in practice, Overa testing would not be necessary if clinical assessment alone indicated cancer. Using Overa testing in this manner guarantees that Overa testing will be more sensitive and less specific than clinical assessment alone, even if it has no better than thechance capability of detecting ovarian cancer. Sensitivity improved from 74% to 94%, and specificity decreased from 93% to 65%.

Table 7. Clinical Validity of the Overa Test Among 493 Patients Evaluated by Nongynecologic Oncologists

Diagnostic Characteristics	Clinical Assessment Alone, %	Dual Assessment With Overa Test, %
Sensitivity (95% CI)	74 (64 to 82)	94 (87 to 97)
Specificity (95% CI)	93 (90 to 95)	65 (60 to 70)
Positive predictive value (95% CI)	70 (62 to 77)	38 (35 to 41)
Negative predictive value (95% CI)	94 (92 to 96)	98 (95 to 99)
Prevalence	19 (92/493)

Adapted from the FDA. 510(k) Substantial Equivalence Determination Decision Summary: OVA1™ Next Generation Test (K150588). n.d.;
CI: confidence interval.

The purpose of the limitations tables (see Tables 8 and 9 ) is to display notable limitations identified in each study. This information is synthesized as a summary of the body of evidence following each table and provides the conclusions on the sufficiency of the evidence supporting the position statement.

Table 8. Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Follow-Upe
FDA 510(k) OVA1 K1505881	4. 70.3% of subjects were white

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.
FDA: Food and Drug Administration.

^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4. Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

Table 9. Study Design and Conduct Limitations

Study	Selectiona	Blindingb	Delivery of Testc	Selective Reportingd	Data Completenesse	Statisticalf
FDA 510(k) OVA1 Next Generation K150588	1. Not described	1. Not described	1. Not described	1. Registration not described	1. Inadequate description of indeterminate and missing samples	None

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.
FDA: Food and Drug Administration.

^a Selection key: 1. Selection not described; 2. Selection not random or consecutive (i.e., convenience).
^b Blinding key: 1. Not blinded to results of reference or other comparator tests.
^c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.
^d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.
^f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Moore et al (2008) described the development of the ROMA test.^16, The authors studied 9 biomarkers and chose HE4 and CA 125 because these markers in tandem produced the best performance. The algorithm developed was subsequently modified to include a menopausal status and was independently validated.^17, Again, separate cutoffs were used for premenopausal and postmenopausal women.

ROMA compared with HE4 and CA 125

Two systematic reviews have compared ROMA with HE4 and CA 125.Wang et al(2014) published a meta-analysis of studies evaluating the clinical validity of the ROMA test algorithm and comparing it with the performance of single biomarkers HE4 and CA 125.^18, To be included in the meta-analysis, studies had to investigate both HE4 and CA 125 or calculate ROMA, enroll women with ovarian cancer and benign gynecologic disease, use pathology diagnosis as the reference standard, and collect blood samples before treatment was initiated. Thirty-two studies met these inclusion criteria; six were conducted in the U. S. Findings of the overall pooled analysis of diagnostic accuracy are presented in Table 10.

Table 10. Characteristics of Systematic Reviews That Compared ROMA with HE4 and CA 125

Study	Tests evaluated (No. Studies)	Study Populations Included	Study Designs Included
Wang et al (2014)	CA 125 (28), HE4 (28), and ROMA (14)	Women with ovarian cancer and benign gynecologic disease	Blinded and unblinded
Dayyani et al (2016)	CA 125 (6), HE4 (6), and ROMA (6)	Women with ovarian cancer	All

CA 125: cancer antigen 125; HE4: human epididymis secretory protein 4.

Table 11. Meta-Analytic Findings for Diagnostic Performance of the ROMA Test vs HE4 and CA 125 from Wang et al (2014).

Test	No. Studies	Sensitivity (95% CI), %	Specificity (95% CI), %
ROMA test	14	85.3 (81.2 to 88.6)	82.4 (77.4 to 86.5)
Human epididymis secretory protein 4	28	76.3 (72.0 to 80.1)	93.6 (90.0 to 95.9)
Cancer antigen 125	28	79.2 (74.0 to 83.6)	82.1 (76.6 to 86.5)

Adapted from Wang et al (2014).^18,
CI: confidence interval; CA 125: cancer antigen 125; HE4: human epididymis secretory protein 4.

Findings were similar when diagnostic performance in premenopausal women and postmenopausal women were evaluated separately. ROMA had similar or higher sensitivity than HE4 and CA 125, and HE4 had the highest specificity.

Dayyani et al(2016) conducted a meta-analysis comparing ROMA with HE4 and CA 125 in patients with suspected ovarian cancer.^19, Six studies met the inclusion criteria, 4 of which were included in the Wang et al (2014) meta-analysis. Two studies were published in 2014 or later. Based on area under the curve analysis, ROMA had higher values than either HE4 (0.921; 95% CI, 0.855 to 0.960) or CA 125 alone (0.899; 95% CI, 0.835 to 0.943) and HE4 plus CA 125 (0.883; 95% CI, 0.771 to 0.950). Findings of the pooled analysis of diagnostic accuracy are shown in Table 12.

Table 12. Meta-Analytic Findings for Diagnostic Performance of the ROMA Test vs HE4 and CA 125 from Dayyani et al (2016)

Test	No. Studies	Sensitivity (95% CI), %	Specificity (95% CI), %
ROMA test	6	87.3 (75.2 to 94.0)	85.5 (71.9 to 93.2)
Human epididymis secretory protein 4	6	68.2 (69.3 to 90.1)	85.1 (71.6 to 92.8)
Cancer antigen 125	6	79.6 (66.3 to 88.5)	82.5 (82.5 to 91.9)

Adapted from Dayyani et al (2016).^19,
CI: confidence interval; CA 125: cancer antigen 125; HE4: human epididymis secretory protein 4.

The point estimates for sensitivity and specificity were lower in pre- and postmenopausal women, with wider confidence intervals.

Since the Wang et al (2014) and Dayyani et al (2016) meta-analyses, multiple studies have compared the use of the ROMA test to HE4 and CA 125 in various subgroups based on menopausal status, the cutoff value used, and different racial/ethnic background.^{20,21,22,23,24,25,26,} These studies demonstrate that ROMA's sensitivity (range, 54.5% to 93%) and specificity (range, 75% to 96%) can vary importantly depending on variation in these factors. For example, in a few recent studies of racial/ethnic subpopulations, ROMA's sensitivity dramatically declined and was lowest when used in a sample of 274 African American women (54.5%; 95% CI 33.7-75.3)^25, and when distinguishing between malignant/borderline vs benign or between malignant and borderline/benign in a sample of 177 premenopausal Korean women (46.4% and 52.6%, respectively).^24, On the other hand, specificity was highest (95.9%) in a subgroup of 104 postmenopausal women when using a "new optimal cutoff value" of 33.4% instead of 29.9%.^22,

ROMA compared with Risk Malignancy Index-I

Chacon et al(2019) conducted a meta-analysis comparing ROMA with RMI for detecting ovarian cancer (Table 13).^27, Among the 2662 women included in the meta-analysis, 50 percent were premenopausal and 50 percent were postmenopausal. Mean ovarian cancer prevalence was 29% in premenopausal women and 51% in postmenopausal women. The majority of studies were conducted at a single-center. Although pooled sensitivities for ROMA (Table 14) were similar to those reported in previous systematic reviews that compared ROMA to HE4 and CA 125, specificities for ROMA were somewhat lower in this meta-analysis (range of 82-85% in Wang et al 2014 and Dayyani et al 2016 meta-analyses compared with 75-78%). However, findings from this meta-analysis by Chacon et al (2019) should be interpreted with caution due to important limitations including a high-risk of selection bias in most studies and significant unexplained statistical heterogeneity in the meta-analyses.

Table 13. Characteristics of Chacon et al (2019) Systematic Review of ROMA compared with RMI

Study	Dates	Studies	Participants	N (Range)	Design	Risk of bias
Chacon et al (2019)	2011-2018	8	Patients in whom both ROMA and RMI, were calculated for predicting malignancy in adnexal masses	2,662 (50-1061)	Prospective (7) and retrospective (1) cohort studies	Based on QUADAS-2 assessment, risk of bias was “high in most studies”, due to “selection bias in that they had selected only women who underwent surgery”

RMI: risk malignancy index.

Table 14. Diagnostic Performance of ROMA compared with RMI from Chacon et al (2019)

Test	Sensitivity (95% CI), %		Specificity (95% CI), %
	Premenopausal	Postmenopausal	Premenopausal	Postmenopausal
ROMA	80% (70-88%)	87% (78–93%)	78% (69-85%)	75% (66–83%)
RMI	73% (62–81%)	77% (65–86%)	89% (83–93%)	85% (73–92%)

CI: confidence interval; RMI: risk malignancy index.
ROMA in Conjunction with Clinical Assessment

The FDA labeling for ROMA, unlike that for OVA1, does not indicate how ROMA is to be used in conjunction with clinical assessment. All previously cited literature assessed ROMA as a stand-alone test for ovarian cancer and did not provide a comparison with clinical assessment alone. The study by Moore et al (2014) evaluated ROMA in conjunction with clinical assessment, using either a positive clinical assessment or a positive ROMA as a positive test (similar to the recommended usage for OVA1).^28, Using this method of combining tests guarantees a higher sensitivity and lower specificity for the combined test than for either test alone. Used in this way, ROMA would only need to be given to patients with a negative clinical assessment. In this study, 461 women were enrolled, of whom 86 (19%) had a malignancy. Combined assessment improved sensitivity from 77.9% to 89.7%, but specificity worsened from 84.3% to 67.2% (see Table 13).

Table 15. Summary of Key Study Characteristics

Study; Trial	Countries	Sites	Dates	Participants	Comparison
					ROMA Group	Comparator
Moore (2014)	U.S.	13	2009 - 2010	Women with an ovarian cyst or pelvic mass (n=461)	ICRA+ROMA	ICRA

ICRA: Initial Cancer Risk Assessment.

Table 16. Diagnostic Performance of the ROMA Test for All Malignancy

Diagnostic Characteristics	Clinical Assessment Alone (95% CI), %	Clinical Assessment With ROMA (95% CI), %
Sensitivity	77.9 (66.2 to 87.1)	89.7 (79.9 to 95.8)
Specificity	84.3 (80.2 to 87.8)	67.2 (62.2 to 71.9)
Positive predictive value	47.3 (37.8 to 57.0)	33.2 (26.4 to 40.5)
Negative predictive value	95.5 (92.6 to 97.4)	97.3 (94.5 to 98.9)

Adapted from Moore et al (2014).^28,
CI: confidence interval.

The purpose of the limitations tables (see Tables 17 and 18) is to display notable limitations identified in each study. This information is synthesized as a summary of the body of evidence following each table and provides the conclusions on the sufficiency of the evidence supporting the position statement.

Table 17. Relevance Limitations

Study	Populationa	Interventionb	Comparatorc	Outcomesd	Follow-Upe
Moore et al (2014)	4. 84.8% of subjects were white; 60.4% of subjects were EOC grade 3; 66.7% had stage III epithelial ovarian cancer

The study limitations stated in this table are those notable in the current review; this is not a comprehensive limitations assessment.

^a Population key: 1. Intended use population unclear; 2. Clinical context is unclear; 3. Study population is unclear; 4. Study population not representative of intended use.
^b Intervention key: 1. Not clearly defined; 2. Version used unclear; 3. Delivery not similar intensity as comparator; 4. Not the intervention of interest.
^c Comparator key: 1. Not clearly defined; 2. Not standard or optimal; 3. Delivery not similar intensity as intervention; 4. Not delivered effectively.
^d Outcomes key: 1. Key health outcomes not addressed; 2. Physiologic measures, not validated surrogates; 3. No CONSORT reporting of harms; 4. Not establish and validated measurements; 5. Clinical significant difference not prespecified; 6. Clinical significant difference not supported.
^e Follow-Up key: 1. Not sufficient duration for benefit; 2. Not sufficient duration for harms.

^a Selection key: 1. Selection not described; 2. Selection not random or consecutive (i.e., convenience).
^b Blinding key: 1. Not blinded to results of reference or other comparator tests.
^c Test Delivery key: 1. Timing of delivery of index or reference test not described; 2. Timing of index and comparator tests not same; 3. Procedure for interpreting tests not described; 4. Expertise of evaluators not described.
^d Selective Reporting key: 1. Not registered; 2. Evidence of selective reporting; 3. Evidence of selective publication.
^e Data Completeness key: 1. Inadequate description of indeterminate and missing samples; 2. High number of samples excluded; 3. High loss to follow-up or missing data.
^f Statistical key: 1. Confidence intervals and/or p values not reported; 2. Comparison with other tests not reported.

Evidence for the clinical validity for the OVA1 and Overa tests include prospective, double-blind studies that have evaluated the clinical validity of these tests in predicting the likelihood of malignancy in women who are planning to have surgery for an adnexal mass. They have not been studied for ovarian cancer screening. The prospective studies showed that, in patients with adnexal mass who had a planned surgical intervention, the use of OVA1 and Overa in conjunction with a clinical assessment by nongynecologic oncologists increased the sensitivity but decreased the specificity compared with clinical assessment alone. When used with clinical assessment in this manner, the sensitivity to ovarian malignancy was 92%, and the specificity was 42%. ROMA is intended for use in conjunction with clinical assessment, but no specific method has been defined. One study, which used clinical assessment and ROMA results, showed a sensitivity of 90% and a specificity of 67%. Two meta-analysis reported less than 90% sensitivity and specificity with ROMA testing.

Clinically Useful

A test is clinically useful if the use of the results informs management decisions that improve the net health outcome of care. The net health outcome can be improved if patients receive correct therapy, or more effective therapy, or avoid unnecessary therapy, or avoid unnecessary testing.

The ideal study design to evaluate the clinical utility of a multimarker serum-based test would be a randomized controlled trial comparing health outcomes (e.g., mortality) in patients managed using the tests with those managed according to best current clinical practices. According to the chain of logic, greater numbers of persons with ovarian cancer referred for surgery by a gynecologic oncology specialist should result in improved overall health outcomes. No randomized or nonrandomized studies with these comparisons were identified.

Although OVA1, Overa, and ROMA, when used in conjunction with clinical assessment, improve the sensitivity for detection of malignancy, the specificity declines. In studies using either positive ROMA or clinical assessment as a positive test, sensitivity improved¾but it was still less than 90%. It is uncertain whether there is meaningful clinical benefit from using a test that avoids a high number of referrals and does not contain sensitive data (even though incrementally better). Because there is no established or recommended method for using ROMA in conjunction with clinical assessment, diagnostic performance characteristics are uncertain because it would vary depending on how it is used.

It is also uncertain whether the incremental yield of malignancy resulting from the use of the tests would result in improved patient outcomes. Although prior studies revealed an improvement of outcomes when women with ovarian cancer were initially managed by gynecologic oncologists, it is uncertain whether improved outcomes would occur in the additional cases detected by the use of these tests. These additional cancer cases may differ from other cases detected by clinical assessment alone. If they tend to be earlier stage cancers or biologically less aggressive cancers, initial treatment by a gynecologic oncologist may not provide incremental benefit.

Section Summary: Clinically Useful

As no trials were identified that have compared health outcomes for patients managed with and without the use of FDA-cleared multimarker serum-based tests, there is no direct evidence of clinical usefulness. It is uncertain whether discrimination is sufficient to alter decision-making based on clinical assessment alone, thus offering a meaningful benefit to patients. Therefore, the chain of evidence supporting improved outcomes is incomplete.

Summary of Evidence

For individuals who have adnexal mass(es) undergoing surgery for possible ovarian cancer who receive multimarker serum testing with clinical assessment preoperatively to assess ovarian cancer risk, the evidence includes studies assessing the technical performance and diagnostic accuracy. The relevant outcomes are overall survival and test accuracy. OVA1 and Overa are intended for use in patients for whom clinical assessment does not indicate cancer. When used in this manner, sensitivity for ovarian malignancy was 92% and specificity was 42% with OVA1; with Overa, sensitivity was 94% and specificity was 65%. ROMA is intended for use with clinical assessment, but no specific method has been defined. One study, which used clinical assessment and ROMA results, showed a sensitivity of 90% and specificity of 67%.However, the National Comprehensive Cancer Network guidelines recommend (category 1) that all patients undergoing surgery should undergo surgery by an experienced gynecologic oncologist. Given the National Comprehensive Cancer Network recommendation, direct evidence will be required to demonstrate that the use of FDA-cleared multimarker serum testing to inform decisions regarding referral to a gynecologic oncology specialist for surgery has clinical usefulness. Direct evidence of clinical usefulness is provided by studies that have compared health outcomes for patients managed with and without the FDA-cleared multimarker serum testing. Because these are intervention studies, the preferred evidence would be from randomized controlled trials. No trials were identified that have evaluated whether referral based on FDA-cleared multimarker serum testing improves health outcomes.

Clinical Input From Physician Specialty Societies and Academic Medical Centers

While the various physician specialty societies and academic medical centers may collaborate with and make recommendations during this process, through the provision of appropriate reviewers, input received does not represent an endorsement or position statement by the physician specialty societies or academic medical centers, unless otherwise noted.

In response to requests, input was received while this policy was under review in 2012. The input was mixed in support of these tests as a tool for triaging patients with an adnexal mass. Reviewers agreed that the evidence was insufficient to determine the impact of these tests on referral patterns. For indications other than triaging patients with an adnexal mass, there was a lack of support for the use of these tests.

SUPPLEMENTAL INFORMATION

Practice Guidelines and Position Statements

American Congress of Obstetricians and Gynecologists

The ACOG addressed the use of the OVA1 test in its 2011 guidelines on the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer,^29, and these guidelines were confirmed in 2017.^30, The Society for Gynecologic Oncology (2013) endorsed these ACOG guidelines.^31, This ACOG document included the following comments, which were not specific guidelines about the use of the test:

• The OVA1 test "appears to improve the predictability of ovarian cancer in women with pelvic masses."
• "This is not a screening test, but it may be useful for evaluating women with a pelvic mass."
• "Clinical utility is not yet established."

National Institute for Health and Care Excellence

The National Institute for Health and Care Excellence (2011) issued guidance on the identification and management of ovarian cancer.^32, This guidance is currently being updated and is under review.

National Comprehensive Cancer Network

The NCCN guidelines on ovarian cancer (v.2.2019) include the following statement^33,:

“It has been suggested that specific biomarkers (serum HE4 [human epididymis secretory protein 4] and CA 125 [cancer antigen 125]) along with an algorithm (Risk of Ovarian Malignancy Algorithm [ROMA]) may be useful for determining whether a pelvic mass is malignant or benign. The FDA [Food and Drug Administration] has approved the use of HE4 and CA-125 for estimating the risk of ovarian cancer in women with a pelvic mass. Currently, the NCCN Panel does not recommend the use of these biomarkers for determining the status of an undiagnosed pelvic mass.”

Regarding the OVA1 test, the NCCN guidelines state:

“The OVA1 test uses 5 markers (including transthyretin, apolipoprotein A1, transferrin, beta-2 microglobulin, and CA 125) to assess who should undergo surgery by an experienced gynecologic oncologist and who can have surgery in the community…. Based on data documenting an increased survival, NCCN Guidelines Panel Members recommend that all patients should undergo surgery by an experienced gynecologic oncologist (category 1).”

U.S. Preventive Services Task Force Recommendations

The U.S. Preventive Services Task Force (2012) recommended against screening women for ovarian cancer (D recommendation).This recommendation was confirmed in their 2018 update.^34, The Task Force has not addressed multimarker serum testing related to ovarian cancer.

Ongoing and Unpublished Clinical Trials

A search of ClinicalTrials.gov in October 2019 did not identify any ongoing or unpublished trials that would likely influence this review.]
________________________________________________________________________________________

Horizon BCBSNJ Medical Policy Development Process:

This Horizon BCBSNJ Medical Policy (the “Medical Policy”) has been developed by Horizon BCBSNJ’s Medical Policy Committee (the “Committee”) consistent with generally accepted standards of medical practice, and reflects Horizon BCBSNJ’s view of the subject health care services, supplies or procedures, and in what circumstances they are deemed to be medically necessary or experimental/ investigational in nature. This Medical Policy also considers whether and to what degree the subject health care services, supplies or procedures are clinically appropriate, in terms of type, frequency, extent, site and duration and if they are considered effective for the illnesses, injuries or diseases discussed. Where relevant, this Medical Policy considers whether the subject health care services, supplies or procedures are being requested primarily for the convenience of the covered person or the health care provider. It may also consider whether the services, supplies or procedures are more costly than an alternative service or sequence of services, supplies or procedures that are at least as likely to produce equivalent therapeutic or diagnostic results as to the diagnosis or treatment of the relevant illness, injury or disease. In reaching its conclusion regarding what it considers to be the generally accepted standards of medical practice, the Committee reviews and considers the following: all credible scientific evidence published in peer-reviewed medical literature generally recognized by the relevant medical community, physician and health care provider specialty society recommendations, the views of physicians and health care providers practicing in relevant clinical areas (including, but not limited to, the prevailing opinion within the appropriate specialty) and any other relevant factor as determined by applicable State and Federal laws and regulations.

___________________________________________________________________________________________________________________________

Index:
Multimarker Serum Testing Related to Ovarian Cancer
Proteomics-Based Testing Related to Ovarian Cancer
Proteomics-Based Testing for the Evaluation of Ovarian (Adnexal) Masses
OVA1 Test
ROMA Test
Risk of Ovarian Malignancy Algorithm
Overa Test

References:
1. Surveillance Epidemology and End Results (SEER) Program. SEER Stat Fact Sheets: Ovarian Cancer. n.d.; https://seer.cancer.gov/statfacts/html/ovary.html. Accessed October 29, 2019.

2. du Bois A, Rochon J, Pfisterer J, et al. Variations in institutional infrastructure, physician specialization and experience, and outcome in ovarian cancer: a systematic review. Gynecol Oncol. Feb 2009;112(2):422-436. PMID 18990435

3. Hoskins W, Rice L, Rubin S. Ovarian cancer surgical practice guidelines. Society of Surgical Oncology practice guidelines. Oncology (Williston Park). Jun 1997;11(6):896-900, 903-894. PMID 9189944

4. Vernooij F, Heintz P, Witteveen E, et al. The outcomes of ovarian cancer treatment are better when provided by gynecologic oncologists and in specialized hospitals: a systematic review. Gynecol Oncol. Jun 2007;105(3):801- 812. PMID 17433422

5. Giede KC, Kieser K, Dodge J, et al. Who should operate on patients with ovarian cancer? An evidence-based review. Gynecol Oncol. Nov 2005;99(2):447-461. PMID 16126262

6. Van Holsbeke C, Van Belle V, Leone FP, et al. Prospective external validation of the 'ovarian crescent sign' as a single ultrasound parameter to distinguish between benign and malignant adnexal pathology. Ultrasound Obstet Gynecol. Jul 2010;36(1):81-87. PMID 20217895

7. Im SS, Gordon AN, Buttin BM, et al. Validation of referral guidelines for women with pelvic masses. Obstet Gynecol. Jan 2005;105(1):35-41. PMID 15625139

8. Simmons AR, Clarke CH, Badgwell DB, et al. Validation of a biomarker panel and longitudinal biomarker performance for early detection of ovarian cancer. Int J Gynecol Cancer. Jul 2016;26(6):1070-1077. PMID 27206285

9. Yanaranop M, Tiyayon J, Siricharoenthai S, et al. Rajavithi-ovarian cancer predictive score (R-OPS): A new scoring system for predicting ovarian malignancy in women presenting with a pelvic mass. Gynecol Oncol. Jun 2016;141(3):479-484. PMID 26996662

10. Guidance for Industry and FDA Staff - Class II Special Controls Guidance Document: Ovarian Adnexal Mass Assessment Score Test System. https://www.fda.gov/regulatory-information/search-fda-guidance-documents/class-ii-special-controls-guidance-document-ovarian-adnexal-mass-assessment-score-test-system. Accessed October 29, 2019.

11. U.S. Food and Drug Administration (FDA). 510(k) Substantial Equivalence Determination Decision Summary: OVA1TM Test (K081754) n.d.; https://www.accessdata.fda.gov/cdrh_docs/reviews/K081754.pdf. Accessed October 29, 2019.

12. Fung ET. A recipe for proteomics diagnostic test development: the OVA1 test, from biomarker discovery to FDA clearance. Clin Chem. Feb 2010;56(2):327-329. PMID 20110452

13. Grenache DG, Heichman KA, Werner TL, et al. Clinical performance of two multi-marker blood tests for predicting malignancy in women with an adnexal mass. Clin Chim Acta. Jan 1 2015;438:358-363. PMID 25283731

14. U.S. Food and Drug Administration (FDA). 510(k) Substantial Equivalence Determination Decision Summary: OVA1TM Next Generation Test (K150588). n.d.; https://www.accessdata.fda.gov/cdrh_docs/reviews/K150588.pdf. Accessed October 28, 2019.

15. Bristow RE, Smith A, Zhang Z, et al. Ovarian malignancy risk stratification of the adnexal mass using a multivariate index assay. Gynecol Oncol. Feb 2013;128(2):252-259. PMID 23178277

16. Moore RG, Brown AK, Miller MC, et al. The use of multiple novel tumor biomarkers for the detection of ovarian carcinoma in patients with a pelvic mass. Gynecol Oncol. Feb 2008;108(2):402-408. PMID 18061248

17. Moore RG, Miller MC, Disilvestro P, et al. Evaluation of the diagnostic accuracy of the risk of ovarian malignancy algorithm in women with a pelvic mass. Obstet Gynecol. Aug 2011;118(2 Pt 1):280-288. PMID 21775843

18. Wang J, Gao J, Yao H, et al. Diagnostic accuracy of serum HE4, CA125 and ROMA in patients with ovarian cancer: a meta-analysis. Tumour Biol. Jun 2014;35(6):6127-6138. PMID 24627132

19. Dayyani F, Uhlig S, Colson B, et al. Diagnostic performance of risk of ovarian malignancy algorithm against CA125 and HE4 in connection with ovarian cancer: a meta-analysis. Int J Gynecol Cancer. Nov 2016;26(9):1586-1593. PMID 27540691

20. Al Musalhi K, Al Kindi M, Al Aisary F, et al. Evaluation of HE4, CA-125, Risk of Ovarian Malignancy Algorithm (ROMA) and Risk of Malignancy Index (RMI) in the preoperative assessment of patients with adnexal mass. Oman Med J. Sep 2016;31(5):336-344. PMID 27602187

21. Cho HY, Park SH, Park YH, et al. Comparison of HE4, CA125, and risk of ovarian malignancy algorithm in the prediction of ovarian cancer in Korean wome. J Korean Med Sci. Dec 2015;30(12):1777-1783. PMID 26713052

22. Terlikowska KM, Dobrzycka B, Witkowska AM, et al. Preoperative HE4, CA125 and ROMA in the differential diagnosis of benign and malignant adnexal masses. J Ovarian Res. Jul 19 2016;9(1):43. PMID 27436085

23. Shen Y, Zhao L, Lu S. Diagnostic performance of HE4 and ROMA among Chinese women.. Clin. Chim. Acta, 2019 Oct 19. PMID 31626761

24. Shin KH, Kim HH, Kwon BS et al. Clinical Usefulness of Cancer Antigen (CA) 125, Human Epididymis 4, and CA72-4 Levels and Risk of Ovarian Malignancy Algorithm Values for Diagnosing Ovarian Tumors in Korean Patients With and Without Endometriosis.. Ann Lab Med, 2019 Aug 23;40(1). PMID 31432638

25. Dunton C, Bullock RG, Fritsche H. Multivariate Index Assay Is Superior to CA125 and HE4 Testing in Detection of Ovarian Malignancy in African-American Women.. Biomark Cancer, 2019 Jun 27;11:1179299X19853785. PMID 31236012

26. Han KH, Park NH, Kim JJ et al. The power of the Risk of Ovarian Malignancy Algorithm considering menopausal status: a comparison with CA 125 and HE4.. J Gynecol Oncol, 2019 Oct 3;30(6). PMID 31576682

27. Chacon E, Das J, Caballero C et al. Risk of Ovarian Malignancy Algorithm versus Risk Malignancy Index-I for Preoperative Assessment of Adnexal Masses: A Systematic Review and Meta-Analysis.. Gynecol. Obstet. Invest., 2019 Jul 17;1-8:1-8. PMID 31311023

28. Moore RG, Hawkins DM, Miller MC, et al. Combining clinical assessment and the Risk of Ovarian Malignancy Algorithm for the prediction of ovarian cancer. Gynecol Oncol. Dec 2014;135(3):547-551. PMID 25449569

29. American College of Obstetricians Gynecologists Committee on Gynecologic Practice. Committee Opinion No. 477: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer. Obstet Gynecol. Mar 2011;117(3):742-746. PMID 21343791

30. American College of Obstetricians Gynecologists Committee on Gynecologic Practice. Committee Opinion No. 716: the role of the obstetrician-gynecologist in the early detection of epithelial ovarian cancer in women at average risk:.https://www.acog.org/Clinical-Guidance-and-Publications/Committee-Opinions/Committee-on-Gynecologic-Practice/The-Role-of-the-Obstetrician-Gynecologist-in-the-Early-Detection-of-Epithelial-Ovarian-Cancer-in?IsMobileSet=false Accessed October 22, 2019.

31. Society of Gynecologic Oncologists. Multiplex Serum Testing for Women with Pelvic Mass. 2013; https://www.sgo.org/newsroom/position-statements-2/multiplex-serum-testing-for-women-with-pelvic-mass/. Accessed October 29, 2019.

32. National Center for Clinical Excellence (NICE). Ovarian cancer: recognition and initial management [CG122]. 2011; https://www.nice.org.uk/guidance/cg122 Accessed October 22, 2019.

33. National Comprehensive Cancer Network (NCCN). NCCN Clinical Practice Guidelines in Oncology: Ovarian Cancer Including Fallopian Tub Cancer and Primary Peritoneal Cancer. Version 2.2019. https://www.nccn.org/professionals/physician_gls/pdf/ovarian.pdf Accessed October 22, 2019.

34. Grossman DC, Curry SJ, Owens DK et al. Screening for Ovarian Cancer: US Preventive Services Task Force Recommendation Statement.. JAMA, 2018 Feb 17;319(6). PMID 29450531

Codes:
(The list of codes is not intended to be all-inclusive and is included below for informational purposes only. Inclusion or exclusion of a procedure, diagnosis, drug or device code(s) does not constitute or imply authorization, certification, approval, offer of coverage or guarantee of payment.)

CPT*

81500
81503
0003U