ROMA CALCULATION TOOL

Using the Elecsys® HE4 and CA 125 II with

menopausal status to determine the risk
assessment for epithelial ovarian cancer

Indication
The ROMA Calculation Tool is a qualitative test for serum and plasma that combines the results of Elecsys® HE4,
Elecsys® CA 125 II and menopausal status into a numerical score. The test is intended to aid in assessing whether a
premenopausal or postmenopausal woman who presents with an ovarian adnexal mass is at high or low probability of
finding malignancy on surgery.

The ROMA Calculation Tool using Elecsys® assays indicated for women who meet the following criteria: over age 18;
ovarian adnexal mass present for which surgery is planned, and not yet referred to an oncologist. ROMA Calculation
Tool results must be interpreted in conjunction with an independent clinical and radiological assessment. The test is not
intended as a screening or stand-alone diagnostic assay.

Explanation of Test
The ROMA Calculation Tool was developed for the estimation of the risk of epithelial ovarian cancer. The algorithm
takes into account the Elecsys HE4 and Elecsys CA 125 II values as well as the menopausal status of the patient. The
algorithm calculates a predictive probability of finding epithelial ovarian cancer on surgery.

A Predictive Index is calculated for premenopausal and postmenopausal patients separately using equations (1) and
(2) below. To calculate the PI, the assay values obtained from the Elecsys HE4 assay and the Elecsys CA 125 II assay
are inserted into the equations below, depending on the menopausal status of the woman.

Predictive Index (PI)

(1) Premenopausal: PI = -12.0 + 2.38 x LN[HE4] + 0.0626 x LN[CA 125]
(2) Postmenopausal: PI = -8.09 + 1.04 x LN[HE4] + 0.732 x LN[CA 125]
To calculate the ROMA Calculation Tool value, insert the calculated value for PI
into equation (3).
(3) ROMA Calculation Tool using Elecsys® assays value = exp(PI) / [1 + exp(PI)] x 10
Where, exp(PI) = ePI

Note: These equations were used for the calculation of ROMA Calculation Tool Using Elecsys® assays values with the
Elecsys® HE4 assay from 15.0 30000 pmol/L (including 1:20 dilution) and with the Elecsys® CA 125 II assay from 2.0
15000 U/mL (including 1:5 dilution).

The ROMA Calculation Tool (algorithm) is used to stratify women into likelihood groups for finding cancer on surgery.
In order to provide a specificity level of 75 %, have a cut-off point of ≥ 1.14 was used for premenopausal women
and ≥ 2.99 was used for postmenopausal women who present with an ovarian adnexal mass. Women with ROMA
Calculation Tool values above these cut-off points are at high likelihood of finding malignancy on surgery.
Interpretation of Results:
Premenopausal women
ROMA Calculation Tool Using Elecsys® assays values ≥ 1.14 = High likelihood of finding
malignancy
ROMA Calculation Tool Using Elecsys® assays values < 1.14 = Low likelihood of finding
malignancy
Postmenopausal women
ROMA Calculation Tool Using Elecsys® assays values ≥ 2.99 = High likelihood of finding
malignancy
ROMA Calculation Tool Using Elecsys® assays values < 2.99 = Low likelihood of finding
malignancy
The reported results include both the likelihood and associated ROMA Calculation Tool Using
Elecsys® assays score for premenopausal and postmenopausal women on a scale of 0‑10.
Stratification of patients into low-risk and high-risk groups
To examine whether the ROMA Calculation Tool using Elecsys® assays provides additional
information when used in combination with the initial cancer risk assessment (ICRA), 455
women with a pelvic mass were enrolled in a prospective, multi center, blinded trial. ICRA was
performed by a physician, nurse practitioner or physician assistant. Histopathology reports were
collected after surgery to determine if the mass was benign or malignant. Of the subjects, 249
were premenopausal and 206 were postmenopausal. In the premenopausal group, 16 subjects
were diagnosed with epithelial ovarian cancer (EOC) or ovarian low malignant potential tumors
(LMP), while 49 women were diagnosed in the postmenopausal group. ROMA Calculation Tool
Using Elecsys® assays scores were calculated using samples collected pre surgery and values
compared to the diagnoses are analyzed below:

All Pre-menopausal Post-menopausal

Histopathological N % N % N %
classification
Benign pathology 371 81.5 228 91.6 143 69.4
Borderline/LMP 18 4 7 2.8 11 5.3
Epithelial ovarian cancer 47 10.3 9 3.6 38 18.4
Non-epithelial ovarian cancer 2 0.4 0 0 2 1
Other gynecologic cancer 9 2 3 1.2 6 2.9
Other cancer 7 1.5 1 4 6 2.9
Metastatic cancer 1 0.2 1 0.4 0 0
Total 455 100 249 100 206 100

Using a preoperatively collected serum sample, ROMA Calculation Tool value using the Elecsys®
HE4 and Elecsys® CA 125 II assays, was determined and the patient was stratified into a low or
high likelihood group for finding malignancy on surgery. Samples were tested on the cobas e 411
analyzer at three US testing sites.
The stratification of patients presenting with an adnexal mass into high likelihood of harboring
malignant disease (epithelial ovarian cancer (EOC), borderline or low malignant potential (LMP)
tumors and other gynecological or non-gynecological cancers) using ROMA Calculation Tool
results above the cut-off point of ≥ 1.14 for premenopausal and ≥ 2.99 for postmenopausal
women by histopathology is shown in the following table:
Pre-menopausal Post-menopausal All
n = 249 n =206 n = 455
n/N % n/N % n/N %

All EOC 9/9(f) 100 34/38(f) 89.5 43/47 91.5

EOC stage I and II 3/3 100 5/9 55.6 8/12 66.7
EOC stage III + IV 5/5 100 28/28 100 33/33 100
LMP tumors 4/7 57.1 9/11 81.8 13/18 72.2
Other cancer (g)
2/5 40 9/14 64.2 11/19 57.9
All cancer and LMP tumors 15/21 71.4 52/63 82.5 67/84 79.8

(f) 1 EOC patient was unstaged

(g) Non-epithelial ovarian cancer; other gynecologic, and non-gynecologic cancers

The performance of ROMA Calculation Tool Using Elecsys® assays for stratification into low
likelihood and high likelihood groups for premenopausal and postmenopausal women with
epithelial ovarian cancer only is shown in the following tables:

Pre-menopausal (N=237) Post-menopausal (N=237)

Estimate 95% CI(h) Estimate 95% CI(h)

Sensitivity 100% (9/9) 66.4% 100% Sensitivity 89.5% (34/38) 75.2% 97%
Specificity 77.6% (177/228) 71.7% 82.9% Specificity 82.5% (118/143) 75.3% 88.4%
TP-FP(i) 77.6% 72.1% 83.2% TP-FP(i) 72.0% 60.2% 83.8%
PPV (j)
15.0% (9/60) 7.1% 26.6% PPV (j)
57.6% (34/59) 44.1% 70.4%
NPV (k)
100% (177/177) 97.9% 100% NPV (k)
97% (118/122) 91.8% 99%
Prevalence 3.8% (9/237) Prevalence 21.0% (38/181)

(h) CI - Confidence Interval

(i) TP-FP=True positive rate-False positive rate
(j) PPV = Postive Predictive Value
(k) NPV= Negative Predictive Value

Adjunctive use of ROMA Calculation Tool with Initial Cancer Risk Assessment
The performance for the adjunctive use of ROMA Calculation Tool Using Elecsys® assays with
ICRA (ROMA Calculation Tool using Elecsys® assays and/or ICRA being positive for high likelihood
of finding malignancy on surgery) was evaluated by calculating sensitivity, specificity, PPV and
NPV. The prevalence was 14.9% (65/436).
Performance of ROMA Calculation Tool Using Elecsys® assays versus ICRA for malignant and non-
malignant cohorts as determined by pathology for diagnosis of EOC including LMP Malignancy by
pathology
 Malignancy by pathology No Malignancy by pathology
ICRA ICRA
Pos Neg Total Pos Neg Total

Pos 47 9 56 Pos 47 9 56
ROMA Neg 3 6 9 ROMA Neg 3 6 9
Total 50 15 65 Total 50 15 65

Performance of ROMA Calculation Tool Using Elecsys® assay, ICRA and the adjunctive use of
ICRA plus ROMA Calculation Tool Using Elecsys® assays for diagnosis of EOC including LMP is
provided below:

ICRA ROMA Adjunctive

Estimate 95% CI(h) Estimate 95% CI(h) Estimate 95% CI(h)
Sensitivity 76.9% 64.8% 86.5% 86.2% 75.3% 93.5% 90.8% 81.0% 96.5%
(50/65) (65/65) (59/65)
Specificity 84.4% 80.3% 87.9% 79.5% 75.0% 83.5% 70.4% 65.4% 75.0%
(313/371) (295/371) (261/371)
PPV 46.3% 36.7% 56.2% 42.4% 33.9% 51.3% 34.9% 27.8% 42.6%
(50/108) (56/132) (59/169)
NPV 95.4% 92.6% 97.4% 97.0% 94.5% 98.6% 97.8% 95.2% 99.2%
(313/328) (295/3.4) (261/267)
TP-FP 61.30% 50.2% 72.4% 65.70% 56.1% 75.2% 61.1% 52.5% 69.7%
PLR (l)
4.92 4.21 3.37 5.26 3.06 2.57 3.65
NLR(m) 0.27 0.17 0.09 0.32 0.13 0.06 0.28

(l) PLR-Positive likelihood ratio

(m) NLR= Negative Likelihood ratio

With adjunctive use of ICRA and ROMA Calculation Tool Using Elecsys® assays for diagnosis
of EOC including LMP, sensitivity for malignancy increased from 76.9 % to 90.8 %. Specificity
for malignancy decreased from 84.4% to 70.4%. PPV for the adjunctive use of ICRA and ROMA
Calculation Tool Using Elecsys® assays decreased from 46.3% to 34.9% due to an increase in the
number of false positive tests. However, NPV of the adjunctive use of ICRA and ROMA Calculation
Tool Using Elecsys® assays increased from 95.4% to 97.8%. This observed increase in NPV was
statistically significant, (P=0.0000) supporting the improved performance with adjunctive use of
ICRA and ROMA Calculation Tool Using Elecsys® assays compared to stand-alone ICRA in ruling
out cancer.
Calculation of Scores-ROMA Calculation Tool Using Elecsys® assays
To install the calculation tool on the computer, use the
following on-screen instructions. Refer to the package
insert for further installation details. Once installed,
the patient Elecsys® HE4 and CA 125 II results from
the Roche analyzer may be entered. “Click” Calculate
Likelihood to calculate the results. The results are
displayed on the right side of the ROMA Calculation
Tool display.
 Elecsys® CA 125 II and Elecsys® HE4 assay characteristics
Elecsys® HE4 Elecsys® CA 125 II
Testing time 18 minute 18 minute

Test One-step sandwich assay One-step sandwich assay

Calibration 2 point 2 point

Traceability HE4 EIA Fujirebio Diagnostics, Inc. Enzymum Test CA 125 II method which in turn has
been standardized against the CA125 II RIA from
Fujirebio Diagnostics, Inc.

Sample material Serum, LiHeparin,K2EDTA, K3-EDTA Serum, Li Heparin,K2EDTA, K3-EDTA

Sample volume 10 ul 20 ul

Detection limit 15.0 pmol/L 0.6 U/mL

Measuring range 15-1500 pmol/L 0.6-5000 U/mL

Repeatability cobas e 601/cobas e 602 cobas e 601/cobas e 602

CV =1.5-1.9% CV =0.9-1.6%

Intermediate imprecision cobas e 601/cobas e 602 cobas e 601/cobas e 602

CV=2.8-3.4% CV=1.5-2.5%

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