publication date: May. 18, 2018
Conversation with The Cancer Letter
Vanderbilt’s Alvarez: Gynecologists must properly assess all patients for cancer before surgery
Betty and Lonnie S. Burnett Professor of Obstetrics and Gynecology, and chair of the Department of Obstetrics and Gynecology,Vanderbilt University Medical Center
Are the estimates in these studies consistent with what you know?
The study evaluated adult women who had hysterectomy or myomectomy from 2014-15 included in the ACS NSQIP database. In the paper, 1.44% had malignancy of the uterus, 0.6% had cervical cancer and 0.19% had ovarian cancer.
While those percentages seem somewhat high, the biggest issue to me is what type of preoperative evaluation are patients having to rule out a potential cancer. Is the issue of occult gynecologic cancer a question of the actual incidence or is it a question of patients not having the appropriate evaluation preoperatively to exclude a gynecologic cancer?
Not surprisingly, the risk of occult cancer was higher in older women, a patient population where the incidence of gynecologic cancer is higher and where appropriate preoperative evaluation is most critical.
What standard preoperative procedures do gynecologists perform on women who would ultimately undergo a hysterectomy or myomectomy?
All patients should be assessed for risk factors of gynecologic cancer and undergo a full history and physical evaluating symptoms and examination findings that may suggest a gynecologic cancer.
Then we need to make sure that patients are up to date cervical cancer screening, that we have evaluated with appropriate biopsies and ultrasound imaging patients with abnormal uterine bleeding to rule out cervical or uterine cancer, and that we preoperatively evaluate with imaging and tumor markers to assess for possible ovarian cancer in a patient undergoing hysterectomy for a pelvic mass.
I think there’s a lot of things that physicians can do prior to doing the hysterectomy to assess for whether or not that patient has cancer. And so, I think what this paper points out is that maybe we are not always doing as good a job as we need to in the preoperative evaluation of patients undergoing hysterectomy to rule out cancer. This was pointed out by the authors in the discussion.
If uterine tissue is, as this study suggests, more likely to contain hidden cancers than previously believed, should gynecologists be evaluating their patients as rigorously as oncologists might?
Gynecologists are well trained in cervical cancer screening, the evaluation of patients with abnormal uterine bleeding or an adnexal mass. In most instances, patients with a gynecologic cancer will have symptoms or physical exam findings suggesting such.
The most difficult cancer to detect preoperatively may be leiomyosarcomas of the uterus. This is an area where physicians need to use good clinical judgment and available guidelines in choosing to do laparoscopic hysterectomy or myomectomy in select patients. Consultation with a gynecologic oncologist when diagnostic tests suggest or confirm a gynecologic malignancy is always wise.
I just think that we have to continue to educate providers on the appropriate evaluation and risk assessment for gynecologic cancer in patients who we think hysterectomy or myomectomy is indicated.
Are biopsies useful for diagnosing uterine cancers, i.e. sarcoma, especially in fibroids? Would this be important, especially for at-risk patients who may undergo morcellation, power or manual?
Cervical cancer screening and endometrial biopsy in the patient with abnormal or postmenopausal bleeding is prudent. Rarely is the diagnosis of leiomyosarcoma made on the basis of an endometrial biopsy. Image guided biopsy of the uterus usually does not provide enough tissue to confirm a diagnosis of leiomyosarcoma and it is not cost effective. I would certainly advocate that physicians use established guidelines regarding morcellation.
What is your main takeaway from the Yale study?
I just think that we have to interpret this data with a little bit of caution. I think this is a very select population of patients with a variety of indications for hysterectomy or myomectomy. The occult cancer rate in a larger group of patients undergoing hysterectomy or myomectomy might be lower, particularly if properly evaluated preoperatively for a gynecologic cancer.
The concern here is that people aren’t doing the appropriate preoperative evaluation to rule out cancer. My guess would be that if everybody had the appropriate evaluation, the actual number of people that had occult cancer would be a much smaller percentage.
I think that it probably represents a failure in our health care system. It just points out an opportunity, from a quality improvement standpoint, to make sure that everybody who is going to have a hysterectomy has the appropriate assessment for the risk of cancer preoperatively.
The take home point is to properly assess all patients for a gynecologic cancer prior to undergoing surgery.
What will it take, and whose responsibility is it?
I think it is the responsibility of all to ensure we are providing the highest quality of care for patients. It is the responsibility of the physician to be as up to date on gynecologic cancer screening and evaluation of patient with risk factors, symptoms or examination findings suggesting a possible gynecologic cancer.
Hospitals have a responsibility to monitor practice patterns and patient outcomes. It is important to assess whether in those cases where we did find an occult cancer—did the patient have appropriate cervical cancer screening? Did she have an endometrial biopsy or ultrasound if she had abnormal bleeding? Did she have imaging studies and tumor markers preoperatively that suggested a benign process if she had a pelvic mass?
Professional societies such as the American College of Obstetricians and Gynecologists and others play an important part in continuing education. The American Board of Obstetrics and Gynecology also plays an important part via its certification and maintenance of certification processes to ensure physicians are providing high quality care.