1. The OVA1 Test Improves the Preoperative Assessment of Ovarian Tumors Frederick Ueland, Chris Desimone, Leigh Seamon, Rachel Ware, Scott Goodrich, Iwona Podzielinski, Lori Sokoll, Alan Smith, Joseph Santoso, John R. van Nagell Jr., Zhen Zhang.

2. NIH Consensus Statement 1994 “Women with ovarian masses who have been identified preoperatively as having a significant risk of ovarian cancer should be given the option of having their surgery performed by a gynecologic oncologist”

3. The OVA1 Test Biomarker panel –CA125, transthyretin (prealbumin), apolipoprotein A1 beta 2 microglobulin, transferrin OvaCalc software algorithm OVA1 risk index, range 0-10 PremenopausalPostmenopausal Low Risk < 5.0< 4.4 High Risk ≥ 5.0≥ 4.4

4. Objectives Evaluate the performance of the OVA1 test alone, and in conjunction with current clinical parameters, in estimating the risk of malignancy in women scheduled for surgery with an ovarian mass.

5. Eligibility Female subjects age 18 years or older Agreeable to phlebotomy Documented ovarian tumor on imaging Planned surgical intervention within 3 months of imaging Signed informed consent

6. Methods 27 primary care and specialty sites throughout U.S. Preoperative evaluation –imaging to confirm ovarian tumor –serum collection for CA125 –physician assessment (cancer? “yes or no”) Centralized assay at Quest Diagnostics Validation assays –Johns Hopkins –Specialty Laboratories Independent data analysis –Applied Clinical Intelligence

7. Study Population All Subjects Non-GO Physicians GO Physicians Patients516269247 Mean age, yr (SD)52 (14)50 (14)55 (14) Median age, yr524854 Range (min, max)18 to 9219 to 9018 to 92 Menopausal Status, n (%) Pre235 (46%)144 (54%)91 (37%) Post281 (54%)125 (46%)156 (63%) Pathology Diagnosis, n (%) Benign ovarian condition355 (69%)197 (73%)158 (64%) Epithelial ovarian cancer (EOC)96 (19%)45 (17%)51 (21%) Other primary ovarian malignancy9 (2%)5 (2%)4 (2%) Low malignant potential (borderline)28 (5%)12 (4%)16 (6%) Non-primary ovarian malignancy with involvement of the ovaries 18 (4%)5 (2%)13 (5%) Non-primary ovarian malignancies with no involvement of ovaries 10 (2%)5 (2%)

8. OVA1 Test Alone Receiving-operator-characteristic Curve Sensitivity92% Specificity43% PPV42% NPV93%

9. PremenopausalPostmenopausal Performance Preoperative assessment Preoperative assessment plus OVA1 Preoperative assessment Preoperative assessment plus OVA1 Sensitivity, %60898198 95% CI46 to 7376 to 9573 to 8794 to 100 Specificity, %83407428 95% CI77 to 8834 to 4867 to 8122 to 35 PPV, %46266949 95% CI34 to 5820 to 3461 to 7643 to 55 NPV, %90948596 95% CI84 to 9386 to 9778 to 9086 to 99 Negative Likelihood Ratio 0.480.270.250.06 95% CI0.33 to 0.690.12 to 0.640.17 to 0.370.02 to 0.25 Prevalence19% (45/235)41% (116/281)

10. non-GO physiciansGO physicians Performance Preoperative assessment Preoperative assessment plus OVA1 Preoperative assessment Preoperative assessment plus OVA1 Sensitivity, %72927899 95% CI61 to 8183 to 9668 to 8594 to 100 Specificity, %83427526 95% CI77 to 8735 to 4967 to 8120 to 33 PPV, %60366343 95% CI50 to 7030 to 4454 to 7236 to 50 NPV, %89938698 95% CI84 to 9386 to 9779 to 9088 to 100 Negative Likelihood Ratio 0.340.200.300.04 95% CI0.23 to 0.490.09 to 0.440.20 to 0.450.01 to 0.31 Prevalence27% (72/269)36% (89/247)

11. OVA1 Sensitivity Tumor subtypeCancer stage StageSensitivity I90% II100% III100% IV100% Epithelial OC99% Non EOC78% LMP75% Metastases94%

12. Conclusions 1.The OVA1 test successfully classifies patients into high or low probability of malignancy. 2.OVA1 has high sensitivity in premenopausal women and all stages of epithelial ovarian cancers. These results are independent of physician specialty. 3.When combined with other clinical information, the OVA1 test can help determine the risk of malignancy for an ovarian tumor before surgery, and facilitate decisions about referral to a gynecologic oncologist.