Fong Lien Kwong

A Cost Consequence Analysis of Seven Diagnostic Strategies for Ovarian Cancer: A Model‐Based Economic Evaluation

ABSTRACT Objective To assess the costs and consequences of seven diagnostic strategies for ovarian cancer in pre‐ and post‐menopausal women with symptoms in secondary care. Design Economic evaluation alongside a prospective single‐arm diagnostic accuracy study. Setting NHS secondary care outpatients (2‐week referrals, clinics, GP referrals, cross‐specialty referrals) and inpatients (emergency presentations to secondary care). Sample Two cohorts of 857 pre‐menopausal and 1242 post‐menopausal women newly presenting to secondary care with symptoms of suspected ovarian cancer. Methods A model‐based cost‐consequence analysis (CCA) was conducted using a decision tree simulating patient pathways over 12 months. Diagnostic accuracy data were sourced from the ROCkeTS study and supplemented by literature. Main Outcome Measures Cancer deaths, correct diagnosis proportion, and diagnostic yield. Results No diagnostic strategy was optimal across all outcomes. Across both cohorts, the Risk of Malignancy Index (RMI) 200 was least expensive but had poor cancer death and diagnostic yield outcomes. The ADNEX 3% strategy had the highest diagnostic yield and lowest cancer mortality but was the most expensive. For pre‐menopausal women, the IOTA ADNEX 10% strategy outperformed ORADS, ROMA, and CA125 in cost and outcomes. For post‐menopausal women, the high cancer prevalence required a trade‐off. In sensitivity analysis, a two‐step IOTA ADNEX 10% strategy outperformed ORADS, ROMA, and CA125 across all three outcomes, making the strategy a more balanced choice in both cohorts. Conclusion At 12 months, no single diagnostic strategy was superior. Early diagnosis requires balancing cancer mortality, diagnostic yield, and cost. The IOTA ADNEX two‐step strategy at a 10% threshold provided the best trade‐off across these factors and is recommended for practice.

Symptom-triggered testing detects early stage and low volume resectable advanced stage ovarian cancer

Investigating harms of testing for ovarian cancer – psychological outcomes and cancer conversion rates in women with symptoms of ovarian cancer: A cohort study embedded in the multicentre ROCkeTS prospective diagnostic study

AbstractObjectiveTo investigate psychological correlates in women referred with suspected ovarian cancer via the fast‐track pathway, explore how anxiety and distress levels change at 12 months post‐testing, and report cancer conversion rates by age and referral pathway.DesignSingle‐arm prospective cohort study.SettingMulticentre. Secondary care including outpatient clinics and emergency admissions.PopulationA cohort of 2596 newly presenting symptomatic women with a raised CA125 level, abnormal imaging or both.MethodsWomen completed anxiety and distress questionnaires at recruitment and at 12 months for those who had not undergone surgery or a biopsy within 3 months of recruitment.Main outcome measuresAnxiety and distress levels measured using a six‐item short form of the State–Trait Anxiety Inventory (STAI‐6) and the Impact of Event Scale – Revised (IES‐r) questionnaire. Ovarian cancer (OC) conversion rates by age, menopausal status and referral pathway.ResultsOverall, 1355/2596 (52.1%) and 1781/2596 (68.6%) experienced moderate‐to‐severe distress and anxiety, respectively, at recruitment. Younger age and emergency presentations had higher distress levels. The clinical category for anxiety and distress remained unchanged/worsened in 76% of respondents at 12 months, despite a non‐cancer diagnosis. The OC rates by age were 1.6% (95% CI 0.5%–5.9%) for age <40 years and 10.9% (95% CI 8.7%–13.6%) for age ≥40 years. In women referred through fast‐track pathways, 3.3% (95% CI 1.9%–5.7%) of pre‐ and 18.5% (95% CI 16.1%–21.0%) of postmenopausal women were diagnosed with OC.ConclusionsWomen undergoing diagnostic testing display severe anxiety and distress. Younger women are especially vulnerable and should be targeted for support. Women under the age of 40 years have low conversion rates and we advocate reducing testing in this group to reduce the harms of testing.

Vulval Flap Reconstruction in Women With Benign, Preneoplastic and Malignant Vulval Conditions: A Prospective Study

ABSTRACTObjectivesTo (i) evaluate the surgical morbidity, (ii) identify correlates of these and, (iii) explore whether flap reconstruction following vulvectomy improves patient symptoms and quality of life.DesignSingle arm prospective study.SettingSingle tertiary vulval centre, UK.PopulationConsecutive cases of women undergoing radical vulvectomy and flap reconstructions for benign and (pre)invasive vulval conditions.MethodsProspective data collection from April 2020–February 2024. All women were given two validated questionnaires preoperatively and at 3‐, 6‐ and 12‐months to evaluate their satisfaction with the aesthetic, genitourinary and psychosexual outcomes.Main Outcome MeasuresEarly and late complications within 30 days. Patient reported outcome measures preoperatively and post‐reconstruction.Results136 flaps in 69 women were analysed. 92.6% (126/136) and 83.1% (113/136) flaps developed none‐to‐mild complications at 7 days, and between days 8 to 30, respectively. Five necrotic flaps in two patients were surgically debrided. All flaps had healed/healing at 30 days. We did not identify any correlates of complications. At 12 months, women reported an improvement in genital symptoms (p < 0.001). 80.4% (37/46) reported no urinary incontinence vs. 48.1% (26/54) preoperatively, p = 0.0038. 24.4% (11/45) were sexually active vs. 9.3% (5/54) preoperatively, p = 0.0410. More women felt attractive (p = 0.0498), were satisfied with their body (p = 0.0407) and comfortable in intimate situations (p = 0.0273). 88.9% (40/45) stated that reconstruction helped with acceptance of their cancer diagnosis and surgery.ConclusionsLocoregional flap reconstruction has low surgical morbidity, leads to a significant improvement in genitourinary and psychosexual functions. In women with cancer, reconstruction supports women to cope with their diagnosis.