Division of Gynecologic Oncology (LJH), and Department of Obstetrics and Gynecology (LJH, ERM), Department of Medicine (MD, LHC), Duke University Medical Center, Durham, NC; Duke Cancer Institute, Durham, NC (LJH, ERM); St. Francis Hospital, Columbus, GA (GPS); Division of Gynecologic Oncology, Department of Obstetrics and Gynecology, San Antonio Military Medical Center, Fort Sam Houston, TX (JCB); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, Universitaire Ziekenhuizen Leuven, Katholieke Universiteit Leuven, Leuven, Belgium (TVG); Division of Gynaecological Oncology, Department of Obstetrics and Gynaecology, MUMC., GROW - School for Oncology and Developmental Biology, Maastricht, the Netherlands (TVG).
J Natl Cancer Inst. 2014 Dec 16;107(1):322. doi: 10.1093/jnci/dju322. Print 2015 Jan.
We compared the estimated clinical outcomes, costs, and physician workload resulting from available strategies for deciding which women with an adnexal mass should be referred to a gynecologic oncologist.
We used a microsimulation model to compare five referral strategies: 1) American Congress of Obstetricians and Gynecologists (ACOG) guidelines, 2) Multivariate Index Assay (MIA) algorithm, 3) Risk of Malignancy Algorithm (ROMA), 4) CA125 alone with lowered cutoff values to prioritize test sensitivity over specificity, 5) referral of all women (Refer All). Test characteristics and relative survival were obtained from the literature and data from a biomarker validation study. Medical costs were estimated using Medicare reimbursements. Travel costs were estimated using discharge data from Surveillance, Epidemiology and End Results-Medicare and State Inpatient Databases. Analyses were performed separately for pre- and postmenopausal women (60 000 "subjects" in each), repeated 10 000 times.
Refer All was cost-effective compared with less expensive strategies in both postmenopausal (incremental cost-effectiveness ratio [ICER] $9423/year of life saved (LYS) compared with CA125) and premenopausal women (ICER $10 644/YLS compared with CA125), but would result in an additional 73 cases/year/subspecialist. MIA was more expensive and less effective than Refer All in pre- and postmenopausal women. If Refer All is not a viable option, CA125 is an optimal strategy in postmenopausal women.
Referral of all women to a subspecialist is an efficient strategy for managing women with adnexal masses requiring surgery, assuming sufficient capacity for additional surgical volume. If a test-based triage strategy is needed, CA125 with lowered cutoff values is a cost-effective strategy.
我们比较了决定哪些附件包块女性应转至妇科肿瘤医生处的可用策略产生的预估临床结局、成本和医师工作量。
我们使用微模拟模型比较了 5 种转介策略：1）美国妇产科医师学会（ACOG）指南，2）多变量指数分析（MIA）算法，3）恶性风险算法（ROMA），4）CA125 单独应用且降低截断值以提高检测敏感性而非特异性，5）转介所有女性（Refer All）。检测特征和相对生存率来自文献以及生物标志物验证研究的数据。医疗费用使用医疗保险报销额估算。旅行费用使用 Surveillance，Epidemiology and End Results-Medicare 和州住院数据库中的出院数据估算。分别对绝经前和绝经后女性（各有 60000 名“受试者”）进行分析，重复 10000 次。
在绝经后女性（与 CA125 相比，增量成本效益比[ICER]为每年每生存寿命[LYS]节省 9423 美元）和绝经前女性（与 CA125 相比，ICER 为每年每生存寿命[LYS]节省 10644 美元）中，与较便宜的策略相比，Refer All 更具成本效益，但会导致每年每专科医生增加 73 例病例。在绝经前和绝经后女性中，MIA 比 Refer All 更昂贵且效果更差。如果 Refer All 不可行，CA125 是绝经后女性的最佳策略。
如果有足够的额外手术量，将所有女性转介给专科医生是管理需要手术的附件肿块女性的有效策略。如果需要基于检测的分诊策略，则降低截断值的 CA125 是一种具有成本效益的策略。
