Reducing Unnecessary Oophorectomies for Benign Ovarian Neoplasms in Pediatric Patients. JAMA 2023 Oct 03;330(13):1247-1254
Date
10/03/2023Pubmed ID
37787794Pubmed Central ID
PMC10548301DOI
10.1001/jama.2023.17183Scopus ID
2-s2.0-85173036083 (requires institutional sign-in at Scopus site) 7 CitationsAbstract
IMPORTANCE: Although most ovarian masses in children and adolescents are benign, many are managed with oophorectomy, which may be unnecessary and can have lifelong negative effects on health.
OBJECTIVE: To evaluate the ability of a consensus-based preoperative risk stratification algorithm to discriminate between benign and malignant ovarian pathology and decrease unnecessary oophorectomies.
DESIGN, SETTING, AND PARTICIPANTS: Pre/post interventional study of a risk stratification algorithm in patients aged 6 to 21 years undergoing surgery for an ovarian mass in an inpatient setting in 11 children's hospitals in the United States between August 2018 and January 2021, with 1-year follow-up.
INTERVENTION: Implementation of a consensus-based, preoperative risk stratification algorithm with 6 months of preintervention assessment, 6 months of intervention adoption, and 18 months of intervention. The intervention adoption cohort was excluded from statistical comparisons.
MAIN OUTCOMES AND MEASURES: Unnecessary oophorectomies, defined as oophorectomy for a benign ovarian neoplasm based on final pathology or mass resolution.
RESULTS: A total of 519 patients with a median age of 15.1 (IQR, 13.0-16.8) years were included in 3 phases: 96 in the preintervention phase (median age, 15.4 [IQR, 13.4-17.2] years; 11.5% non-Hispanic Black; 68.8% non-Hispanic White); 105 in the adoption phase; and 318 in the intervention phase (median age, 15.0 [IQR, 12.9-16.6)] years; 13.8% non-Hispanic Black; 53.5% non-Hispanic White). Benign disease was present in 93 (96.9%) in the preintervention cohort and 298 (93.7%) in the intervention cohort. The percentage of unnecessary oophorectomies decreased from 16.1% (15/93) preintervention to 8.4% (25/298) during the intervention (absolute reduction, 7.7% [95% CI, 0.4%-15.9%]; Pā=ā.03). Algorithm test performance for identifying benign lesions in the intervention cohort resulted in a sensitivity of 91.6% (95% CI, 88.5%-94.8%), a specificity of 90.0% (95% CI, 76.9%-100%), a positive predictive value of 99.3% (95% CI, 98.3%-100%), and a negative predictive value of 41.9% (95% CI, 27.1%-56.6%). The proportion of misclassification in the intervention phase (malignant disease treated with ovary-sparing surgery) was 0.7%. Algorithm adherence during the intervention phase was 95.0%, with fidelity of 81.8%.
CONCLUSIONS AND RELEVANCE: Unnecessary oophorectomies decreased with use of a preoperative risk stratification algorithm to identify lesions with a high likelihood of benign pathology that are appropriate for ovary-sparing surgery. Adoption of this algorithm might prevent unnecessary oophorectomy during adolescence and its lifelong consequences. Further studies are needed to determine barriers to algorithm adherence.
Author List
Minneci PC, Bergus KC, Lutz C, Aldrink J, Bence C, Breech L, Dillon PA, Downard C, Ehrlich PF, Fallat M, Fraser JD, Grabowski J, Helmrath M, Hertweck P, Hewitt G, Hirschl RB, Kabre R, Lal DR, Landman M, Leys C, Mak G, Markel T, Pressey J, Raiji M, Rymeski B, Saito J, Sato TT, St Peter SD, Cooper J, Deans K, Midwest Pediatric Surgery ConsortiumAuthors
Christina Bence MD Assistant Professor in the Surgery department at Medical College of WisconsinDave Lal MD, MPH Chief, Professor in the Surgery department at Medical College of Wisconsin
MESH terms used to index this publication - Major topics in bold
AdolescentAlgorithms
Child
Female
Hospitalization
Humans
Ovarian Neoplasms
Ovariectomy
Predictive Value of Tests
Preoperative Care
Retrospective Studies
Risk Assessment
Unnecessary Procedures
Young Adult