This document summarizes information on biomarkers for ovarian cancer, including CA-125, HE4, and risk algorithms like ROMA and OVA1. It discusses several studies on the diagnostic performance of these biomarkers alone and in combination for detecting ovarian cancer, especially early-stage disease. The document also reviews recommendations and guidelines for the use of CA-125 testing in different clinical contexts. Finally, it presents findings from a study showing that hormone receptor expression levels have prognostic value for survival in certain ovarian cancer histological subtypes.

1. Biomarkers: current status and
development
Mauricio Lema-Medina MD
Clínica de Oncología Astorga / Clínica SOMA, Medellín
@onconerd

2. @onconerd

3. 0 22.5 45 67.5
90
Advanced
Early
Ovarian Cancer - 5-yr Overall Survival
De Angelis R. Lancet Oncol. 15, 23–34 (2014)

4. Cell-Type

5. Potential Cellular Origins of<br />Ovarian Carcinomas
Presented By Bradley Monk at 2019 ASCO Annual Meeting

6. Khalid EB. Cell Oncol, 2017
Lack p53 mutation
Frequent KRAS and BRAF mutations

7. Association of Ki67 expression levels and therapy
outcome in low-grade serous ovarian cancer
Grabowsky JP, Proc. ASCO, 2019
Ki 67<3.6% is
associated with a
longer TFI
- OR = 17.6, 95%CI
1.56-197.52, p = 0.020
-

8. Khalid EB. Cell Oncol, 2017
96% with inactivating p53 mutation
Frequent NF1 and RB1 mutations
20%

9. Epithelial Ovarian Cancer Subtypes Are Associated <br />With Different Mutations and Molecular Aberrations
Presented By Bradley Monk at 2019 ASCO Annual Meeting

10. Ca-125… and the like

12. Ca 125
Wikipedia
Large
transmembrane
glycoprotein
Unknown
function

13. Ca 125
PDB - http://www.rcsb.org/3d-view/1IVZ/0
Large
transmembrane
glycoprotein
Unknown
function
Frequently
elevated in OC
Also altered by:
Race/Ethnicity
Age
Smoking history
Histerectomy
SEA domain of the Ca 125 (MUC16)

14. High Ca 125 Normal Ca 125
Ovarian cancer 399 106 505
No ovarian
cancer
250 1137 1387
649 1243 1892
Dayyani F. Int. J. Gynecol. Cancer 26, 1586–1593 (2016)
Diagnostic Performance of Risk of Ovarian Malignancy Algorithm
Against CA125 and HE4 in Connection With Ovarian Cancer: A Meta-
analysis
Pelvic mass

15. High Ca 125 Normal Ca 125
Ovarian cancer 399 106 505
No ovarian
cancer
250 1137 1387
649 1243 1892
Dayyani F. Int. J. Gynecol. Cancer 26, 1586–1593 (2016)
Diagnostic Performance of Risk of Ovarian Malignancy Algorithm
Against CA125 and HE4 in Connection With Ovarian Cancer: A Meta-
analysis
Sensitivity: 399 / 505 = 79%
Specificity: 1137 / 1387 = 82%
Pelvic mass

16. NCCN NIH NCAB EGTM ESMO
Early detection in
hereditary cancer synd.
Yes Yes Yes Yes None
Differential diagnosis
in pelvic mass
Yes Yes Yes Yes None
Monitoring response
to therapy
Yes None Yes Yes Yes
Detection of
recurrence
Yes Yes Yes Yes Yes
Prognosis None Yes Yes No Yes
Recommendations for Ca 125 testing (2015)
Abbreviations: NCCN, National Comprehensive Cancer Network; NIH, National Institutes of Health; NACB, National Academy for Clinical Biochemistry; EGTM, European
Group on Tumor Markers; ESMO, European Society for Medical Oncology
King GGT - https://emedicine.medscape.com/article/2087557-overview#a1

17. PLCO
Buys S (PLCO), JAMA, 2011
Women
55-74 yo
Ca 125
qYear x6
TV US
qYear x4
Usual care
R
Median Follow-up: 12.4 y
Endpoint: mortality from ovarian cancer
Secondary outcomes included
ovarian cancer incidence and
complications associated with
screening examinations and
diagnostic procedures
n=78216
n=39105
n=39111

18. PLCO
Buys S (PLCO), JAMA, 2011
Outcomes Screening Usual care RR
Cases of OC 212 176
Incidence
(/10.000 person-years)
5.7 4.7 1.21 (NS)
Deaths due to OC 118 100
OC Mortality
(/10.000 person-years)
3.1 2.6 1.18 (NS)
False positive 3285
Unnecessary surgery 1080
Serious complications 163 (15%)
Mortality
(/10.000 person-years)
76.6 76.2 1.01 (NS)
OC: Ovarian cancer, NS: Non-significant (statistically)

19. PLCO
Buys S (PLCO), JAMA, 2011
Stage III/IV: Screening: 77% / Usual care: 78%

20. PLCO
Buys S (PLCO), JAMA, 2011
Among women in the general US
population, simultaneous screening with
CA-125 and transvaginal ultrasound
compared with usual care did not
reduce ovarian cancer mortality.
Diagnostic evaluation following a false-
positive screening test result was
associated with complications

21. y in the UK Collaborative Trial of Ovarian Cancer Screening (UK
Jacobs IJ (UKCTOCS), Lancet, 2015
Women
50-74 yo
MMS
USSR
Endpoint: death
due to ovarian
cancer
MMS: Multimodal screening (Ca 125 and ROCA algorithm)
USS: transvaginal ultrasound
n=202.638
n=50.640
n=50.639
No screening
n=101.359
Duration of the
intervention:
6 annual screening
over 7 years

22. y in the UK Collaborative Trial of Ovarian Cancer Screening (UK
Outcomes MMS USS No screening
Cases of OC 338 (0.7%) 314 (0.6%) 630 (0.6%)
Deaths due to OC 148 (0.29%) 154 (0.30%) 347 (0.34%)
Mortality reduction
over years 1-14
15% (NS) 11% (NS) NA
Jacobs IJ (UKCTOCS), Lancet, 2015
MMS: Multimodal screening (Ca 125 and ROCA algorithm)
USS: transvaginal ultrasound

23. y in the UK Collaborative Trial of Ovarian Cancer Screening (UK
Jacobs IJ (UKCTOCS), Lancet, 2015
MMS: Multimodal screening (Ca 125 and ROCA algorithm)
USS: transvaginal ultrasound

24. y in the UK Collaborative Trial of Ovarian Cancer Screening (UK
Jacobs IJ (UKCTOCS), Lancet, 2015
MMS: Multimodal screening (Ca 125 and ROCA algorithm)
USS: transvaginal ultrasound
Cumulative ovarian cancer deaths in
MMS and no screening groups after
exclusion of prevalent cases

25. NCCN NIH NCAB EGTM ESMO
Early detection in
hereditary cancer synd.
Yes Yes Yes Yes None
Differential diagnosis
in pelvic mass
Yes Yes Yes Yes None
Monitoring response
to therapy
Yes None Yes Yes Yes
Detection of
recurrence
Yes Yes Yes Yes Yes
Prognosis None Yes Yes No Yes
Ca screening
(general population)
No No No No No
Recommendations for Ca 125 testing (2015)
Abbreviations: NCCN, National Comprehensive Cancer Network; NIH, National Institutes of Health; NACB, National Academy for Clinical Biochemistry; EGTM, European
Group on Tumor Markers; ESMO, European Society for Medical Oncology
King GGT - https://emedicine.medscape.com/article/2087557-overview#a1

26. y in the UK Collaborative Trial of Ovarian Cancer Screening (UK
High-risk gBRCA
Sensitivity 95% 86%
Specificity 99% 99%
NPV 100% 100%
PPV 11% 43%
Rosenthal A, JCO, 2017
MMS: Multimodal screening (Ca 125 and ROCA algorithm)
NPV: Negative-predictive value
PPV: Positive-predictive value
MMS screening in High-risk and gBRCA mutated

27. ACR
(2017)
ACS
(2017)
ACOG
(2017)
NCCN
(2017)
ASCO
(2018)
TV ultrasound
May be
offered*
May be
offered
May consider if
surgery delayed
May consider if
surgery delayed
Periodic
Start … … 30-35 y 30-35 y 30-35 y
End … …
Until risk
reduction surgery
Until risk
reduction surgery
Until risk
reduction surgery
Ca125
Start
End
endations for ovarian cancer screening in gBRCA
Abbreviations: ACOG = American College of Obstetricians and Gynecologists, ACR = American College of Radiology, ACS = American Cancer Society, ASCO = American
Society of Clinical Oncology, CA-125 = cancer antigen 125, CE = contrast enhanced, NCCN = National Comprehensive Cancer Network
Elezaby M, Radiology, 2019*Strong evidence unavailable

28. ACR
(2017)
ACS
(2017)
ACOG
(2017)
NCCN
(2017)
ASCO
(2018)
TV ultrasound
May be
offered*
May be
offered
May consider if
surgery delayed
May consider if
surgery delayed
Periodic
Start … … 30-35 y 30-35 y 30-35 y
End … …
Until risk
reduction surgery
Until risk
reduction surgery
Until risk
reduction surgery
Ca125
May be
offered*
May be
offered
May consider if
surgery delayed
May consider if
surgery delayed
Periodic
Start … … 30-35 y 30-35 y 30-35 y
End … …
Until risk
reduction surgery
Until risk
reduction surgery
Until risk
reduction surgery
endations for ovarian cancer screening in gBRCA
Abbreviations: ACOG = American College of Obstetricians and Gynecologists, ACR = American College of Radiology, ACS = American Cancer Society, ASCO = American
Society of Clinical Oncology, CA-125 = cancer antigen 125, CE = contrast enhanced, NCCN = National Comprehensive Cancer Network
Elezaby M, Radiology, 2019*Strong evidence unavailable

29. NCCN NIH NCAB EGTM ESMO
Early detection in
hereditary cancer synd.
Yes Yes Yes Yes None
Differential diagnosis
in pelvic mass
Yes Yes Yes Yes None
Monitoring response
to therapy
Yes None Yes Yes Yes
Detection of
recurrence
Yes Yes Yes Yes Yes
Prognosis None Yes Yes No Yes
Ca screening
(general population)
No No No No No
Recommendations for Ca 125 testing (2015)
Abbreviations: NCCN, National Comprehensive Cancer Network; NIH, National Institutes of Health; NACB, National Academy for Clinical Biochemistry; EGTM, European
Group on Tumor Markers; ESMO, European Society for Medical Oncology
King GGT - https://emedicine.medscape.com/article/2087557-overview#a1

30. Ca-125 surveillance

31. How many of you perform
routine Ca 125
surveillance?
Raise your hands if
you don’t

32. Early versus delayed treatment of relapsed ovarian
cancer (MRC OV05/EORTC 55955): a randomised trial
Rustin CG, Lancet, 2010
Women in CR
with normal Ca
125 after 1st-
line platinum-
based chemo
Ca 125 q3m
(Masked)
Early Chemo
Ca 125 >2 x
ULN
Delayed
Chemo
R
Endpoint: OS
Early Chemo
Delayed
Chemo
Comments
Number 265 264
Deaths at 59.6
mo
186 184 HR: 0.98
Median OS 25.7 mo 27.1 mo NS

33. Use of CA-125 Tests and Computed Tomographic
Scans for Surveillance in Ovarian Cancer.
Esselen KM, JAMA Oncol, 2016
Years 2004-2009 2010-2012 Comments
Ca 125 ≥3
times a year
86% 91%
In 1241
patients
CT ≥1 times a
year
81% 78%

35. NCCN NIH NCAB EGTM ESMO
Early detection in
hereditary cancer synd.
Yes Yes Yes Yes None
Differential diagnosis
in pelvic mass
Yes Yes Yes Yes None
Monitoring response
to therapy
Yes None Yes Yes Yes
Detection of
recurrence
Yes Yes Yes Yes Yes
Prognosis None Yes Yes No Yes
Ca screening
(general population)
No No No No No
Recommendations for Ca 125 testing (2015)
Abbreviations: NCCN, National Comprehensive Cancer Network; NIH, National Institutes of Health; NACB, National Academy for Clinical Biochemistry; EGTM, European
Group on Tumor Markers; ESMO, European Society for Medical Oncology
King GGT - https://emedicine.medscape.com/article/2087557-overview#a1

36. Composite serum
biomarkers

37. Ovarian carcinomas express HE4 epitopes independently
of each other.
Hellstrom I, Cancer Treat Res Commun, 2019
Expression of HE4 by most ovarian carcinomas makes it an excellent biomarker.

38. Risk of Ovarian Malignancy Algorithm (ROMA)
http://romatools.he4test.com/calculator_row_en.html

39. Risk of Ovarian Malignancy Algorithm (ROMA)
- Prospective validation -
Cited in: Khalid EB. Cell Oncol, 2017
Pelvic Mass
(n=472)
ROMA
(Ca 125/HE4)
89 cases of
ovarian
cancer
Sensitivity Specificity NPV
All 94% 75% 98%
Pre-menopausal 100% 74.2
FDA approved OC risk estimation in pelvic masses

40. A comparison of CA125, HE4, risk ovarian malignancy
algorithm (ROMA), and risk malignancy index (RMI) for
the classification of ovarian masses
Anton C. Clinics (Sao Paulo), 2012
Pelvic Mass
(n=128)
Ca 125
HE4
ROMA
RMI
Sensitivity Ca 125 HE4 ROMA RMI
Differentiation Benigh
Malignant
70% 80% 74% 63%
OC 94% 87% 87% 87%
There were no differences in accuracy between CA125, HE4,
ROMA, and RMI for differentiating between types of ovarian masses
ROMA: Risk of Ovarian Malignancy Algorithm, RMI: Risk Malignancy Index

41. Development of a multimarker assay for early
detection of ovarian cancer
Yurkovetsky Z. JCO, 2010
xMAP
(Ca125, HE4,
CEA, VCAM)
Early-stage OC (n=139)
Diagnostic performance
Sensitivity for Early-Stage OC 86%
Sensitivity for Late-Stage OC 93%
Specificity 98%
Prospective validation: Sensitivity 86%, specificity 95%
Late-stage OC (n=149)
Normal (n=1102)

42. OVA1
Miller RW. Obstet. Gynecol., 2117
Ca-125
Trasthyretin
APOA-1
B2 microglobulin
TF
Diagnostic performance
Sensitivity 94%
Specificity 35%
PPV 40%
NPV 93%
FDA approved OC risk estimation in pelvic masses

43. Multiplexed biomarker
Bionano-chip (p-BNC) with an immunoanalyzer
system
Multi-marker panel comprising CA-125, HE4, MMP-7
and CA72.4
CA-125/ hKs assay
Sensitivity: 74%, Specificity: 97%

44. Other biomarkers
p21
p57
p27
RB1
BCL-2
VEGF
Protein z

45. Hormone-Receptor
Expression

46. Hormone-receptor expression and OC survival
Sieh W, Lancet Oncol, 2013
2933 patients
Invasive Serous,
Endometrioid,
Mucinous or
Clear-Cell OC
Tissue Micro-Arrays
Relevant clinical info

47. Images courtesy Ursula Matulonis, MD.
Serous
Endometrioid
Mucinous
Clear cell
Histological Categories of Ovarian Cancer
Serous Mucinous
Endometrioid Clear-Cell
High HR
expression
Low HR
expression

48. Hormone-receptor expression and OC survival
Sieh W, Lancet Oncol, 2013
PR expression in (A) HGS and © endometrioid
PR and ER are prognostic biomarkers HGS and endometriosis OC

49. Hormone-receptor expression and OC survival
Sieh W, Lancet Oncol, 2013
ER expression in (A) HGS and (C) endometrioid

50. Hormone-receptor expression and OC
survival:
an OTTA consortium study
Sieh W, Lancet Oncol, 2013
HGS
ER+/PR-
(53%)
LGS
ER+/PR-
(34%)
HGS
ER+/PR+
(28%)
LGS
ER+/PR+
(55%)
HGS: High-grade serous, LGS: Low-grade serous

51. Effect of estrogen and progesterone receptor
expression on progression-free and overall survival
outcomes in low-grade serous ovarian cancer.
Llaurado M, Proc. ASCO, 2019
High HR associated
with better OS in
LGS OC

52. BRCA and the like

53. Is there any doubt that most
HGS OC patients need at
least gBRCA assessment?
Raise your hands if
you don’t

54. e Olaparib in Patients with Newly Diagnosed Advan
Moore K, NEJM, 2091
>18 years of age
Stage III or IV
High-grade serous or endometrioid
Ovarian cancer, PPC, fallopian tube cancer
Deleterious gBRCA1/2 or sBRCA1/2 mutation
Post upfront or interval cytoreductive
Post platinum-based chemotherapy (no
bevacizumab)
CR, PR or CR with abnormal Ca 125
Olaparib
Placebo
R
Endpoint: PFS
2:1

55. SOLO-1: PFS by investigator assessment (Efficacy)
Presented By Bradley Monk at 2019 ASCO Annual Meeting

56. Germline mutation profile among Hispanic women with
epithelial ovarian cancer (EOC)
Chavarri-Guerra Y, Proc. ASCO, 2019

57. Germline mutation profile among Hispanic women with
epithelial ovarian cancer (EOC)
Chavarri-Guerra Y, Proc. ASCO, 2019

58. Maintenance Therapy in Platinum-Sensitive, Recurre
Platinum-sensitive recurrent ovarian cancer
Classified as gBRCA1/2 or nonBRCA1/2
Niraparib
maintenance
Placebo
R
Endpoint: PFS
2:1
Mansoor RM, NEJM, 2016

59. Elucidation of PARP inhibitor activity in BRCAwt
recurrent ovarian cancer by hrr mutational gene profile
analysis
ENGOT-OV16/NOVA
553 patients enrolled
gBRCAmut (n=203) Non-gBRCAmut (n=350)
HRD+ (n=162) HRD- (n=134) HRD N/A (n=54)
sBRCAmut+ (n=47) sBRCAwt+ (n=115)
Mansoor RM, Proc. ASCO, 2019

60. Elucidation of PARP inhibitor activity in BRCAwt
recurrent ovarian cancer by hrr mutational gene profile
analysis
ENGOT-OV16/NOVA
553 patients enrolled
gBRCAmut (n=203)
Mansoor RM, Proc. ASCO, 2019

61. Maintenance Therapy in Platinum-Sensitive, Recurre
Mansoor RM, NEJM, 2016

62. Elucidation of PARP inhibitor activity in BRCAwt
recurrent ovarian cancer by hrr mutational gene profile
analysis
Mansoor RM, Proc. ASCO, 2019
ENGOT-OV16/NOVA
553 patients enrolled
Non-gBRCAmut (n=350)
HRD+ (n=162)

63. Elucidation of PARP inhibitor activity in BRCAwt
recurrent ovarian cancer by hrr mutational gene profile
analysis
HRD (Homologous-Recombination
Deficiency) score by Myriad
myChoice
LOH: Loss of heteroziygocity
LST: Large-scale state transitions
TAI: Telomeric allelic imbalance
Mansoor RM, Proc. ASCO, 2019

64. Maintenance Therapy in Platinum-Sensitive, Recurre
Mansoor RM, NEJM, 2016

65. Elucidation of PARP inhibitor activity in BRCAwt
recurrent ovarian cancer by hrr mutational gene profile
analysis
Mansoor RM, Proc. ASCO, 2019
ENGOT-OV16/NOVA
553 patients enrolled
Non-gBRCAmut (n=350)
HRD+ (n=162)
sBRCAmut+ (n=47) sBRCAwt+ (n=115)
HRRmut (n=41)

66. Elucidation of PARP inhibitor activity in BRCAwt
recurrent ovarian cancer by hrr mutational gene profile
analysis
Mansoor RM, Proc. ASCO, 2019
ENGOT-OV16/NOVA
553 patients enrolled
gBRCAmut (n=203) Non-gBRCAmut (n=350)
HRD+ (n=162) HRD- (n=134) HRD N/A (n=54)
sBRCAmut+ (n=47) sBRCAwt+ (n=115)
HRRmut (n=41)

67. Elucidation of PARP inhibitor
activity in BRCAwt recurrent
ovarian cancer by hrr
mutational gene profile analysis
Mirza RM, Proc. ASCO, 2019
HRR genes
ATM
BAP1
BARD1
BRCA1
BRCA2
BRIP1
CHEK2
MRE11A
NBN
PALB2
RAD50
RAD51B
RAD51C
RAD51D
RAD54B
RAD54C
ATR
XRCC2
XRCC3
18 GENES
Myriad NGS

68. ATM
BRCA1/BARD1
heterodimer
BRCA2-DSS1
MRE11
PALB2-BRCA2
complex
CHEK2
ATR-
ATRIP
XRCChttp://www.rcsb.org

69. RAD51
Interacts with
BRCA2
RAD52
RAD54
http://www.rcsb.org

70. PARP1
PARP1-inhibitor
http://www.rcsb.org

71. Elucidation of PARP inhibitor activity in BRCAwt
recurrent ovarian cancer by hrr mutational gene profile
analysis
Mansoor RM, Proc. ASCO, 2019

72. Elucidation of PARP inhibitor activity in BRCAwt
recurrent ovarian cancer by hrr mutational gene profile
analysis
Mansoor RM, Proc. ASCO, 2019

73. Maintenance Therapy in Platinum-Sensitive, Recurre
Mansoor RM, NEJM, 2016

74. Conclusions
● Ca 125
● May be useful for the w/u of an ovarian mass
● Doubtable usefulness in other settings
● Multiplex serum biomarkers
● A little better than Ca 125 alone
● Of little clinical significance
● BRCA
● Essential for HGS OC in all, but the very early-stage, OC patients
● NGS for BRCA-like signatures and other HRR-related genes
● May expand the use of iPARP to some wtBRCA1/2

75. @onconerd

76. TCGA
The Cancer Genome Atlas

77. Integrated genomic analyses of ovarian carcinoma
TCGA, Nature, 2012

78. Integrated genomic analyses of ovarian carcinoma
TCGA, Nature, 2012
RB and PI3K/RAS signaling

79. Integrated genomic analyses of ovarian carcinoma
TCGA, Nature, 2012
NOTCH signaling

80. Integrated genomic analyses of ovarian carcinoma
TCGA, Nature, 2012
HR alterations

81. Integrated genomic analyses of ovarian carcinoma
TCGA, Nature, 2012
FOXM1 signaling

82. Integrated genomic analyses of ovarian carcinoma
TCGA, Nature, 2012
FOXM1 signaling
AurB (AURKB), CCNB1,
BIRC5, CDC25 and PLK1,
were consistently
overexpressed but not
altered by DNA copy
number changes, indicative
of transcriptional regulation
p53
HRR
(via ATM)