How relevant are ACOG and SGO guidelines for referral of adnexal mass?

To evaluate referral guidelines published by American College of Obstetricians and Gynecologists (ACOG) and Society of Gynecologic Oncologists (SGO), which provide guidance about when to refer a patient with a pelvic mass to a gynecologic oncologist.

Data from consecutive patients evaluated for pelvic mass were collected prospectively over a 5-year period. The performance characteristics of the ACOG/SGO referral guidelines for detection of primary and metastatic ovarian cancer were calculated by using menopausal status, CA 125 level, imaging results, physical findings, and family history.

Eight hundred thirty-seven patients met inclusion criteria. Forty-four percent (263/597) of postmenopausal women were diagnosed with ovarian cancer, whereas 20% (48/240) of premenopausal women had ovarian cancer. Seventy-four percent of primary cancers were stage III or IV. The referral guidelines were 79.2% sensitive and 69.8% specific for premenopausal women, with a positive predictive value of 39.6%. For postmenopausal women, the guidelines were 93.2% sensitive and 59.9% specific, and positive predictive value was 64.6%. The referral guidelines performed better for late-stage than early-stage cancers in both sensitivity and positive predictive value, especially in postmenopausal women. Although only 28 patients would not have been referred by the guidelines, the majority of these had early stage (I or II) disease. Lowering the CA 125 cutoff level required for referral of premenopausal patients increased the sensitivity of the guidelines in this group.

The ACOG/SGO guidelines perform well in predicting advanced-stage ovarian cancer, probably owing to the nature of advanced-stage disease. The guidelines perform poorly in identifying early-stage disease, especially in premenopausal women, primarily due to lack of early markers and signs of ovarian cancer.