Esther Lems

Do we more often opt for conservative management of ovarian tumors after changing the Dutch national guideline on enlarged ovaries? A nationwide cohort study

AbstractIntroductionIncreasing evidence shows that conservative management of ovarian tumors classified as benign, based on ultrasound assessment, is safe. Therefore, conservative management has been adopted as the preferred strategy for certain ovarian tumors assessed as benign in the Dutch national guideline on enlarged ovaries in 2013. The aim of this study was to examine whether implementation of this guideline has led to changes in the number of women/100 000 women undergoing surgery for an ovarian tumor in the Netherlands.Material and MethodsHistopathology reports were requested for all examinations of ovarian and fallopian tube specimens (including cyst enucleations) registered in Palga, the Dutch nationwide pathology databank, from 2011 (before guideline adaptation) and 2019 (after guideline adaptation). Reports on prophylactically removed adnexa, removal for other primary tumors (eg endometrial carcinoma), and for patients under 18 years of age, were excluded from the analysis. Interobserver agreement for the inclusion and classification of reports was assessed using Cohen's Kappa analysis.ResultsA total of 34 932 reports were retrieved, 13 917 of which were included in the analysis. In 2011 and 2019, respectively, 96.3/100 000 vs 68.8/100 000 women aged ≥18 underwent surgery for benign ovarian tumors, and 19.6/100 000 vs 18.3/100 000 for borderline and malignant tumors combined. The number of women/100 000 who had surgery for a benign ovarian tumor per 100 000 women declined by 28.5% (p < 0.001) between 2011 and 2019. The largest difference between 2011 and 2019 was observed in the number of women per 100 000 women who underwent surgery for a serous cystadenoma (−40.7%; 20.8/100 000 vs. 12.3/100 000), followed by endometrioma (−33.2%; 14.7/100 000 vs. 9.8/100 000), simple epithelial cyst (−57.3%; 8.4/100 000 vs. 3.6/100 000), and corpus luteum cyst (−57.0%; 4.0/100 000 vs. 1.7/100 000). Cohen's Kappa for the interobserver agreement was 0.96.ConclusionsThe number of women/100 000 undergoing surgery for a benign ovarian tumor has substantially decreased in the Netherlands when comparing data before and after implementation of the national guideline in 2013, while the number of women/100 000 undergoing surgery for a malignant or borderline tumor remained the same. These findings suggest successful implementation of the updated guideline, and a measurable effect on increased adoption of conservative management for benign‐looking ovarian tumors.

Current uptake and barriers to wider use of the International Ovarian Tumor Analysis (IOTA) models in Dutch gynaecological practice

Correct referral of women with an ovarian tumor to an oncology department remains challenging. The International Ovarian Tumor Analysis (IOTA) consortium has developed models with higher diagnostic accuracy than the alternative Risk of Malignancy Index (RMI). This study explores the uptake of the IOTA models in Dutch hospitals and factors that impede or promote implementation. Optimal implementation is crucial to improve pre-operative classification of ovarian tumors, which may lead to better patient referral to the appropriate level of care. In February 2021, an electronic questionnaire consisting of 37 questions was sent to all 72 hospitals in the Netherlands. One pre-selected gynaecologist per hospital was asked to respond on behalf of the department. The study had a response rate of 93% (67/72 hospitals). All respondents (100%) were familiar with the IOTA models with 94% using them in practice. The logistic regression 2 (LR2)-model, Simple ultrasound-based rules (SR) and Assessment of Different NEoplasias in the adneXa (ADNEX) model were used in respectively 40%, 67% and 73% of these hospitals. Respondents rated the models overall with an 8.2 (SD 1.8), 8.3 (SD 1.6) and 8.9 (SD 1.3) respectively for LR2, SR and ADNEX on a scale from 1 to 10. Moreover, 89% indicated to have confidence in the results of the IOTA models. The most important factors to improve further implementation are more training (43%), research on sensitivity, specificity and cost-effectiveness in the Dutch health care system (27%), easier usability (24%) and more consultation time (19%). The IOTA ultrasound models are adopted in the majority of Dutch hospitals with the ADNEX model being used the most. While Dutch gynecologists have a strong familiarity and confidence in the models, the uptake varies in reality. Areas that warrant improvement in the Dutch context are more uniformity, education and more research. These findings can be helpful for other countries considering adopting the IOTA models.

Real-world performance of the Assessment of Different NEoplasias in the adneXa (ADNEX) model for the pre-operative classification of ovarian tumors.

To predict the risk of malignancy in ovarian tumors, the multi-class risk prediction Assessment of Different NEoplasias in the adneXa (ADNEX) model of the International Ovarian Tumor Analysis group is used internationally. This study aimed to perform an external validation of this model in a real-world clinical setting in the Netherlands. A multi-center, retrospective diagnostic accuracy study was performed. Women aged ≥18 years who attended the outpatient clinic between May 2020 and December 2021 and had a first ultrasound assessment for an ovarian tumor with application of the International Ovarian Tumor Analysis ADNEX model were included. The reference standard was the pathology result in case of surgery or follow-up with ultrasound according to the current Dutch guideline in case of conservative management. Of the 363 women included, 286 (78.8%) had benign, 24 (6.6%) had borderline, and 53 (14.6%) had malignant pathology. Most (62.5%) of the included patients underwent surgery. The area under the receiver operating characteristic (ROC) curve was 0.92 (95% CI 0.89 to 0.96) if borderline tumors were considered malignant and 0.93 (95% CI 0.89 to 0.96) if borderline tumors were considered benign. Cutoff values between 7% and 14% yielded the highest Youden index. The model was moderately able to differentiate between malignant histologic sub-types. The ADNEX model showed excellent diagnostic performance in daily clinical practice and retained its value in a population in which a proportion of patients were treated with conservative management.