publication date: May. 18, 2018

Conversation with The Cancer Letter

Yale’s Desai: Gynecologists must preoperatively workup and discuss the risks, benefits, alternatives

Vrunda Desai

Vrunda Desai

Assistant professor of obstetrics, gynecology, and reproductive sciences, Yale University School of Medicine

 

Matthew Ong:

What led you and your team to conduct these large studies on the prevalence of undetected uterine cancers in women undergoing hysterectomies and myomectomies for benign indications? Did the studies stem from the debate over power morcellation?

Vrunda Desai:

We were interested in learning more about the rates of occult gynecological cancer during hysterectomy and myomectomy.

When we learned that the American Cancer Society- National Surgical Quality Improvement Program (ACS-NSQIP) provided chart abstracted data including pathology we thought that this would be a good data set to examine.

Though we have been aware of the FDA recommendations and clinical practice changes occurring from the morcellation debate, this was not the primary focus of this research project.

 

MO:

What did you think you’d find, and were you surprised by the results? Did you expect them to be as dramatic as they are?

VD:

We aimed to obtain the most accurate assessment of the rates of occult gynecological cancer in the patients having a hysterectomy or myomectomy for assumed benign conditions.

The elevated cancer rates noted,  specifically in women over the age of 55, are similar to previous studies which demonstrate a link with increasing age and occult cancer rates.

 

MO:

Before your team’s paper, did the existing literature provide a reliable prevalence estimate for occult uterine malignancies? Are your findings completely new and unprecedented?

VD:

Prior studies have often been smaller in scope, focusing on a specific types of gynecological cancer, and in volume, often at examining single academic institutions.

We were excited to use the NSQIP data as it includes about 100 hospitals and the data are not just based on claims coding but are instead abstracted by a team of trained abstractors.

 

MO:

What are the implications of your research for women’s health? When gynecologists perform surgeries that are not oncologically-safe (i.e. electromechanical or manual morcellation), do we now know that women face a higher risk for dissemination of all kinds of uterine malignancies, not just sarcoma or leiomyosarcoma?

VD:

We hope that our study increases the awareness and discussion of occult cancer risk in the thousands of women undergoing hysterectomy and myomectomy annually.

Morcellation of a specimen allows for the dissemination of cancer. Having an informed conversation with patients preoperatively is essential to this process.

 

MO:

How authoritative are the results of your team’s research? Can policymakers rely on your findings to make public health decisions?

VD:

Our goal was to provide as accurate as possible assessment of occult cancer in women undergoing hysterectomy and myomectomy as the majority of these procedures are performed for benign indications.

As with all research there are limitations to our study, specifically that we were unable to assess preop indication from the NSQIP data. We aim to have additional analysis to further identify the occult cancer rates in these clinical scenarios.

 

MO:

The CDC has expressed an interest in taking action, based on your research. If you were asked to provide a recommendation, what would your suggestion to the CDC be? 

VD:

To provide the highest quality of care to our patients, it is essential to preoperatively workup and discuss the risks, benefits and alternatives of the treatment options available.

We hope that our research will encourage practitioners to continue to have these conversations with their patients as each case is individualized and inherently has unique aspects.

 

MO:

Do the high prevalence rates in your findings signal a need for improving preoperative evaluation and management of women undergoing uterine surgical procedures? If so, does the standard of care in gynecology need to change? How?

VD:

Our study highlights that in particular patient populations (older patients, specifically over 55) and those undergoing specific surgical routes of hysterectomy, thorough preoperative assessment is necessary.

The NSQIP data does not include preoperative work up so we are unable to assess this with our current research.

 

MO:

What preoperative procedures do you use when evaluating women who would ultimately undergo a hysterectomy or myomectomy? How often are preoperative biopsies done in women undergoing hysterectomies or myomectomies?

VD:

Currently endometrial biopsy, sampling of the uterine lining, is often performed for patients preoperatively prior to gynecological surgery, particularly in patients with abnormal uterine bleeding or postmenopausal bleeding.

Inherently, a biopsy is a small sample of the tissue and cannot definitively exclude cancer, especially in cases where a focal lesion is present (fibroids or polyps).

 

MO:

Is there a discrepancy between the routine use of biopsies in gynecological evaluation of potentially malignant masses (i.e. fibroid tumors), and the routine use of biopsies in other surgical specialties?

VD:

Fibroid masses are commonly removed surgically for treatment of symptoms either by myomectomy or hysterectomy based on a variety of patient specific factors including fertility preservation.

Endometrial biopsy provides a general assessment of the uterine lining not specifically of the fibroid mass.

 

MO:

Are biopsies useful or sensitive enough in diagnosing occult uterine malignancies, for instance, sarcoma in the corpus uteri or in leiomyoma?

VD:

Women often have multiple fibroids so in addition to the limited diagnostic ability of a small biopsy it may be difficult to determine where and how many biopsies to obtain to accurately assess for cancer.

 

MO:

Based on your findings, should morcellation continue to be used in hysterectomies, or should it be reserved only for uterus-sparing myomectomies in women who would like to preserve fertility?

VD:

Following the FDA’s recommendation, the use of morcellation in hysterectomy has declined significantly, with clinicians utilizing alternative surgical options for specimen removal.

The paramount focus is on providing high quality care safely to our patients and discussion on specific surgical techniques utilized should be individualized with patients and their providers.

 

MO:

Did we miss anything? Any other thoughts or suggestions?

VD:

Thanks for your interest in our research!

Copyright (c) 2018 The Cancer Letter Inc.