It is important to identify those likely to be malignant and use the most effective referral and management strategy to maximize survival. A variety of referral algorithms have been proposed to help decide which women are most likely to benefit from referral and initial surgery by a subspecialist. Because of the absence of effectiveness studies directly comparing different available referral algorithms, use of computer simulation and decision models is a formal way to estimate the likely costs, clinical outcomes, and expected increased workload with each strategy for managing women with an adnexal mass.
This study used a modified Markov microsimulation model to compare the estimated costs, clinical outcomes, and workload impact of 5 referral strategies to determine which women with an adnexal mass should be referred to a gynecologic oncologist. Referral strategies compared were the following: (1) American Congress of Obstetricians and Gynecologists guidelines, (2) Multivariate Index Assay (MIA) algorithm, (3) Risk of Malignancy Algorithm, (4) CA-125 alone with lowered cutoff values to prioritize test sensitivity over specificity, and (5) referral of all women (Refer All). Test characteristics and relative survival data were obtained from the literature and a biomarker validation study. Costs of medical care were estimated using national Medicare reimbursements, and costs of travel to a generalist or subspecialist were estimated using discharge data from the Surveillance, Epidemiology and End Results–Medicare and State Inpatient Databases. Separate microsimulation models were performed for premenopausal and postmenopausal women (60,000 subjects in each menopausal category), repeated 10,000 times.
Compared with less expensive strategies, Refer All is cost-effective in both postmenopausal (incremental cost-effectiveness ratio [ICER] $9423/year of life saved [YLS] vs CA-125) and premenopausal women (ICER $10,644/YLS vs CA-125), but would increase the workload of each subspecialist by an additional 73 cases per year. For both premenopausal and postmenopausal women, MIA is more expensive and less effective than Refer All. If Refer All is not a practical option, CA-125 is an optimal cost-effective strategy in both premenopausal and postmenopausal women, although there is more uncertainty for premenopausal women.
These findings suggest that referral of all women with adnexal masses requiring surgery to a subspecialist is a cost-effective strategy in both premenopausal and postmenopausal women.