Is That Pelvic Mass an Ovarian Cancer? CA125, HE4, and ROMA

One of the famous sayings of my historical hero, Ben Franklin, was “an ounce of prevention is worth a pound of cure.” The ancient Roman poet, Persius, suggested even more succinctly that it’s best to “meet the malady on its way.” This sage advice certainly applies in the world of cancer. Since it’s not currently possible to completely eliminate all risk of cancers (despite the rants of many unethical product pushers), the next best thing is to find it early. When it comes to ovarian cancer, even that task has been “easier said than done.”

Roughly 20,000 women are diagnosed and almost 15,000 die of ovarian cancer in the United States each year. This relatively high death rate is due largely to our historical inability to find these cancers in an early stage. Over the past several decades, many attempts have been made to diagnose ovarian cancers earlier. None of these efforts have proven particularly fruitful. Symptoms of the disease aren’t usually present until the cancer is in a more advanced stage, having spread outside the ovary to other sites in the pelvis or the abdomen.

A related common scenario faced by gynecologists and their patients, however, is that of the ovarian or “adnexal mass.” Thousands of women each year, some with symptoms and some without, are found to have a mass on one side of their pelvis or the other, usually found by CT or ultrasound imaging. The dilemma for gynecologic surgeons has been in determining which of these women require an operation. Who among these women is harboring an ovarian cancer?

Over the past several years, gynecologic oncologists have been working on blood tests that might help them determine which of these women with pelvic masses on CT or ultrasound actually has ovarian cancer that requires major surgery. The first reasonable modern blood test in that regard was the CA-125 test. For patients already diagnosed with ovarian cancer and under treatment, this test is an excellent marker of how well patients are responding to therapy. As a screening tool by itself for women with ovarian masses, however, the CA-125 test falls short. Over the past few years, doctors at Brown University have developed an algorithm using both the CA-125 and a newer blood test called HE4 to help determine if a pelvic mass represents an ovarian cancer, prior to potential surgery:

This Risk of Ovarian Malignancy Algorithm (ROMA) appears to be a fairly effective way to tell if a pelvic mass has a high likelihood of being an ovarian cancer. General gynecologists may use the ROMA to decide whether women should be referred to a gynecologic oncologist who specializes in women’s cancers. The test is a product of Fujirebio Diagnostics: (I don’t currently own the stock or have any relationship with the company.) While we have plenty of room for improvement in the early diagnosis and treatment of women with ovarian cancer, ROMA appears to be a step in the right direction.

– Patrick Maguire MD


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