1. Frederick R. Ueland, M.D. Associate Professor Gynecologic Oncology University of Kentucky Markey Cancer Center

2. Siena, Italy Settled 900-400 BC Walled city by 12 th century 1 st Palio race in 1656

3. Il Palio di Siena

4. Outline ■ The challenge of ovarian tumors ■ Value of specialists in ovarian cancer ■ Essentials in preoperative evaluation  Examination  Imaging  Biomarkers ■ Algorithms  ACOG  RMI ■ Summary

5. Challenge of Ovarian Tumors There are 155 million women in United States  ~125 million women 13 years of age or older 90 million are between 13 and 50 years of age 30 million are over age 50 How common are ovarian tumors?  Premenopausal 14% annual incidence (13 million), 30% prevalence (27 million)  Postmenopausal 5% annual incidence (1.5 million), 16% prevalence (5 million)  Resolution: 70% of unilocular, 55% of complex tumors Millions of ovarian tumors, 22,000 cancers annually Which tumors need removal and by whom? United States Census Bureau, 2008; Data from University of Kentucky Ovarian Cancer Screening Program, 2009 (N=27,000)

6. Many tumors, few cancers  Low prevalence 15% of ovarian neoplasms are malignant  Germ cell tumors  Borderline tumors  Epithelial cancers Benign ovarian tumors  70% functional cysts  20% neoplastic  10% endometrioma s Other  Inflammatory Few tumors, many cancers  High prevalence 50% of ovarian neoplasms are malignant  Epithelial ovarian cancer  Metastatic cancer  Granulosa cell tumors Benign ovarian tumors  Cystadenoma  Fibroma  Thecoma Ovarian Tumors PremenopausalPostmenopausal

7. Cancer Mortality 1930-2003 Age-adjusted to the 2000 US standard population. Source: US Mortality Public Use Data Tapes 1960-2003, US Mortality Volumes 1930-1959, National Center for Health Statistics, Centers for Disease Control and Prevention, 2006 Colon & rectum Uterus Stomach Ovary Rate Per 100,000

8. NIH Consensus Statement 1994 “Women with ovarian masses identified preoperatively as having a significant risk of cancer should be given the option of surgery performed by a gynecologic oncologist”

9. Value of Specialists Meta-analysis of 18 studies concluded marked benefit with gynecologic oncologist (Giede 2005)  Complete surgical staging with early disease  Optimal cytoreductive surgery with advanced disease  Improved median and overall survival Involvement of GO supported by:  NCCN guidelines  SGO, ACOG  SOGC clinical practice guidelines  NIH  London Medical Advisory statement

16. Preoperative Evaluation Physical examination  Pelvic, abdominal, and lymph node survey Imaging study  Transvaginal ultrasonography  CT scan Biomarkers  CA125 Not FDA-cleared as a diagnostic test Low sensitivity and specificity

17. Pelvic Examination Detecting ovarian tumors Ovarian palpation is difficult in older women, obese women, and when the uterus is large Ueland et al. Gyn Oncol, 2005 Pelvic Exam Ultrasound P-value Age ≥ 550.300.74 < 0.001 Patient wt ≥ 200 lb0.090.73 < 0.001 Uterine wt ≥ 200 g0.160.80 < 0.001

18. Ultrasound Ovarian tumors Unilateral Simple, unilocular Septated (MI < 5) No ascites Resolution Bilateral Complex (MI ≥ 5)  Solid wall abnormalities  Internal papillations Ascites Persistence or growth BenignMalignant

19. When Cysts are NOT Malignant Unilocular cysts Septated ovarian cysts Saunders B. et al. Risk of Sonographically confirmed septated cystic ovarian tumors. Gynecol Oncol 118: 278-282, 2010. Modesitt et al. Risk of malignancy in unilocular ovarian cystic tumors. Gynecol Oncol 102:594-599, 2003

20. Ultrasound Kentucky Morphology Index Ueland et al. Gynecol Oncol, 2003 Ascites 

21. Kentucky Morphology Index 20 32 38 9277 83 Ueland et al. Gynecol Oncol, 2003 Sensitivity0.98 Specificity0.81 PPV0.41 NPV0.99

22. Ovarian Tumor Ultrasound Definition of (+) US varied with each author AuthorNPrevalenceSens (%)Spec (%)PPV (%)PPV (20%) Kobayashi, 19764061570733139 Hermann, 19872412182937573 Finkler, 19881023662958875 Benacerraf, 19901003080877262 Granberg, 19901802282927473 Sassone, 199114310100833759 Ueland, 20034421298814156

23. CA125 HE4 CEA CA19-9 ■ LDH ■ β-hCG ■ AFP ■ OVA1 Ovarian Biomarkers

24. CA125 Antigen derived from:  Coelomic epithelium (pericardium, pleura, peritoneum)  Mullerian epithelium (tubal, endometrial, endocervical) Two different assays  Assay I < 35 U/ml; Assay II < 20 U/ml Expressed by 80% non-mucinous EOC Low sensitivity (false negatives)  50% sensitivity in early stage ovarian cancers  20-25% false negatives in advanced stage cancers Mucinous, clear cell cancers, mixed mullerian tumors FDA-cleared to monitor cancer treatment Neither a screening nor a diagnostic test

25. CA125 Non-specific Benign ovarian cysts Uterine leiomyomata Pelvic inflammatory disease Endometriosis Adenomyosis Pregnancy Menstruation Ascites Heart failure Liver failure Renal failure Peritoneal tuberculosis Diverticulitis Pancreatitis Recent abdominal or thoracic surgery Other malignancies

26. 1.Quest Diagnostics Website www.questdiagnostics.comwww.questdiagnostics.com 2.He4 Product Insert, Fujirebio Diagnostics, Inc. Antigen derived from: Human epididymis protein Product of the WFDC2 (HE4) gene that is over- expressed in patients with ovarian carcinoma 1 FDA-cleared to monitor cancer treatment with other clinical methods HE4 not for monitoring mucinous or germ cell ovarian cancers 2 ■ Neither a screening nor a diagnostic test HE4

27. Risk of Malignancy Algorithm CA125 and HE4 Accrual from tertiary centers Moore R, et al. A novel multiple marker bioassay utilizing HE4 and CA125 for the prediction of ovarian cancer in patients with a pelvic mass. Gynecol Oncol 2009;112:40-46. All Subjects (N= 503) Premenopausal (N= 236) Postmenopausal (N= 267) Sensitivity897692 Specificity75 PPV603474 NPV949593 Prevalence= 34%

28. CEA  Mucinous neoplasms CA19-9  Gastrointestinal (pancreatic) LDH*  Dysgerminoma *Most beneficial in young women with solid tumors ■ β-hCG* ■ Pregnancy ■ Trophoblastic disease ■ Choriocarcinoma ■ AFP* ■ Hepatic neoplasms ■ Endodermal sinus tumors Other Ovarian Biomarkers

34. FDA NEWS RELEASE For Immediate Release: Sept. 11, 2009 Media Inquiries: Peper Long, 301-796-4671, mary.long@fda.hhs.gov Consumer Inquiries: 888-INFO-FDA FDA Clears a Test for Ovarian Cancer Test can help identify potential malignancies, guide surgical decisions The U.S. Food and Drug Administration today cleared a test that can help detect ovarian cancer in a pelvic mass that is already known to require surgery. The test, called OVA1, helps patients and health care professionals decide what type of surgery should be done and by whom.

35. OVA1 Panel: CA125-II, transthyretin, apolipoprotein A1, beta 2 microglobulin, transferrin Sensitivity  EOC 99%, nonEOC 78%, borderline 75%, metastases 94%  Stage I 90%, stage II-IV 100% Range 0-10 PremenopausalPostmenopausal Low Risk < 5.0< 4.4 High Risk ≥ 5.0≥ 4.4 Presented at SGO Annual Meeting, San Francisco, CA March, 2010

37. ACOG Referral Guidelines CA125 >200 U/mL Ascites Evidence of abdominal or distant metastases Family history one or more first-degree relatives with ovarian or breast cancer CA125 >35 U/mL Nodular or fixed mass Ascites Evidence of abdominal or distant metastases Family history one or more first-degree relatives with ovarian or breast cancer Premenopausal WomenPostmenopausal Women ACOG Committee Opinion: number 280, December 2002. Obstet Gynecol 2002;100:1413-6

38. ACOG Validation Im, 2005  Chart review 1035 patients, 7 tertiary centers  95%- imaging, 68%- CA125, 24%- both  “SGO and ACOG referral guidelines effectively separate women with pelvic masses into two risk categories for malignancy” Dearking, 2007  Prospective, single-institutional trial, 837 patients  Guidelines performed well in predicting advanced- stage disease, but “poorly” in early-stage disease, and premenopausal women  “Need a more sensitive biomarker”  Recommended modifications: CA-125 >67 U/mL (pre); exclude FH of breast, ovarian cancer

39. OVA1 Trial 27 sites throughout United States  516 patients,161 malignancies  52% from primary care providers Preoperative evaluation  Physician assessment  Imaging, serum Biomarker assays- Quest laboratories  Johns Hopkins Biomarker Discovery Center  Specialty Laboratories Independent data analysis  Applied Clinical Intelligence Presented at SGO Annual Meeting, San Francisco, CA March, 2010

40. ACOG Performance All Subjects (N= 516) Premenopausal (N= 235) Postmenopausal (N= 281) ACOG Modified ACOG ACOG Modified ACOG ACOG Modified ACOG Sensitivity778058768481 95% CI70 to 8373 to 8543 to 7161 to 8677 to 9073 to 87 Specificity687177705671 95% CI63 to 7266 to 7571 to 8364 to 7749 to 6464 to 77 PPV525538 5866 95% CI46 to 5849 to 6127 to 5028 to 4850 to 6558 to 74 NPV8788899284 95% CI82 to 9084 to 9283 to 9287 to 9676 to 9077 to 89 Presented at SGO Annual Meeting, San Francisco, CA March, 2010

41. ACOG Performance Premenopausal women Cancer Stage EarlyLate Sensitivity47100 95% CI26 to 6972 to 100 Specificity77 95% CI71 to 83 PPV1619 95% CI8 to 2811 to 31 NPV94100 95% CI89 to 9798 to 100 Presented at SGO Annual Meeting, San Francisco, CA March, 2010

42. ACOG Revisited OVA1 replacing CA125 All subjects N=516 Premenopausal N= 235 Postmenopausal N= 281 Sensitivity949195 95% CI89 to 9779 to 9789 to 98 Specificity354326 95% CI30 to 4036 to 5019 to 33 PPV402847 95% CI35 to 4521 to 3541 to 54 NPV939588 95% CI87 to 9689 to 9875 to 94 Presented at SGO Annual Meeting, San Francisco, CA March, 2010

43. ACOG Performance Univariate comparison ACOG CriteriaModified ACOG Criteria Odds Ratio (95% CI) P ValueOdds Ratio (95% CI) P Value Menopausal status3.0<.0013.0<.001 CA125-II level11.6<.0019.3<.001 Ascites7.8<.0017.8<.001 Evidence of metastasis11.7<.00111.7<.001 Nodular or fixed mass3.3<.001-- FH of breast cancer1.90.036-- FH of ovarian cancer1.50.332-- Presented at SGO Annual Meeting, San Francisco, CA March, 2010

44. ACOG Simplified* 1. OVA1 (+) 2. Nodular or fixed mass 3. Ascites 4. Metastases *presence of any criterion warrants referral to a gynecologic oncologist Sensitivity93% Specificity40% PPV41% NPV93%.

45. Risk of Malignancy Index U x M x CA125 USMenoSizeCA125 HR Score RMI 1Jacobs 19900, 1, 31, 3NAU/mL>200 RMI 2Tingulstad 19961, 4 NAU/mL>125 RMI 3Tingulstad 19991, 3 NAU/mL>200 RMI 4Yamamoto 20061, 4 1, 2*U/mL>450 RMI 5Lee 2010??NAU/mL? *<7 cm or ≥7 cm

46. Risk of Malignancy Index Cutoff = 200 Manjunath et al. Gynecol Oncol 81:225-229, 2001.

47. Ultrasound with Biomarker US* with OVA1US* with CA125 n/NSensitivity95% CIn/NSensitivity95% CI All stages 3 102/1059792 to 9982/1057869 to 85 Stage I 28/319075 to 9716/315235 to 68 Stage II 18/1810082 to 10014/187855 to 91 Early stage (I & II) 46/499484 to 9830/496147 to 74 Late stage (III & IV) 54/5410093.4 to 10052/549688 to 99 Premenopausal women Early stage (I & II) 14/178259 to 945/172913 to 53 Late stage (III & IV) 10/1010072 to 1009/109060 to 98 Postmenopausal women Early stage (I & II) 32/3210089 to 10025/327861 to 89 Late stage (III & IV) 44/4410092 to 10043/449888 to 100 *US= solid, papillary projections, ascites only Data from OVA1 trial presented at SGO, 2010

48. Correlation of OVA1 and Cancer High risk imagingLow risk imaging OVA1 score% MalignantOdds Ratio% MalignantOdds Ratio 4.4 as cut-off 50.58.816.75.2 5.0 as cut-off 51.74.916.33.3 6.0 as cut-off 66.18.424.44.9 7.0 as cut-off 79.513.431.65.4 8.0 as cut-off 82.512.050.010.6 9.0 as cut-off 84.810.9100.0NC

52. Evaluation of an ovarian tumor Unilocular/septate Complex morphology 1 US surveillance every 3-4 months CA125 ( or OVA1; RMI; ACOG ) Surgery with gynecologist Surgery with gynecologic oncologist US surveillance every 6 months persistentlow riskhigh risk 2 *Perform tumor morphology indexing (MI) 1 Complex morphology: solid or papillary areas, ascites, metastases, or MI ≥ 5 2 High risk: CA125 > 200 U/mL (pre), >35 U/mL (post), OVA1 (+), RMI > 200, or per ACOG guidelines Ovarian tumor ultrasound * complex low risk

54. Patient Referrals Specificity doesn’t correlate with referral decisions Ovarian cancer prevalence for GYO  20-40% OVA1 trial  72% of all benign tumors referred to GYO for surgery  45% referred despite a NEGATIVE physician assessment  Physicians lack confidence in impression  Non-medical factors