The recent publication on 'HE4, CA-125, and cystic ovarian mass' is very interesting [1]. Partheen et al. [1] concluded that HE4 did not outperform CA-125. Indeed, the use of two biomarkers might be expected for increased screening ability; however, the problem of the cost should be kept in mind. Incremental analysis on additional cost should be done. Based on the present report, the question is whether it should recommend screening for both HE4 and CA-125 in the patient presenting with a suspicious mass at ovary. This topic is the further point for future studies as indicated in many recent studies [1,2]. Finally, the use of additional means, such as ROMA algorithm and symptom index, to add more value of using HE4 and CA-125 screening should also be further assessed [2,3].

We would like to thank professor Wiwanitkit for his interest in our recent publication 'HE4, CA-125, and cystic ovarian mass'. It is important to emphasize that our report concerns the use of HE4 and CA-125 as a tool when a pelvic mass or cyst already has been found and the question of referral or not to a specialized gynecologic-oncology surgical unit has to be answered. In our study the use of Risk of Malignancy Algorithm (ROMA) was also evaluated. Our study is however not focusing on screening of the general population and subsequently symptom index was not used. Nevertheless we agree that a thorough economical analyze of cost and evaluation of possible patient morbidity should be performed before implementation into clinical practice.