publication date: May. 25, 2018

Letter to the Editor

Noorchashm: Uterine cancers are not “occult” if gynecologists don’t bother to look

 

Hooman Noorchashm

Hooman Noorchashm, MD, PhD

 

Dear Editor,

As you know, a team of gynecological researchers from Yale University recently reported that the incidence of “missed” cancers in women undergoing general gynecological operations of the uterus approaches 2%. Even more staggering is the reported 10% incidence in such women, over the age of 55.

Despite reporting such a staggering frequency of “missed” gynecological cancer, it is concerning that the Yale authors, like most gynecologists, appear quite relaxed about this level of risk in their paper’s discussion—foremost because this level of oncological risk in women undergoing non-oncological operations is an iatrogenic mortality risk.

In fact, the Yale authors seem quite comfortable labeling these cancers as being “occult”—as though a best effort was made to pinpoint the cause of symptoms where the cancer was truly hidden.

But, as The Cancer Letter’s reporting revealed, what is not looked for cannot be found.

So it’s a serious professional misrepresentation for any gynecologist to describe the cancers quantified by the Yale group as being “occult”, when they are in truth “missed” because of the laxity in preoperative tissue diagnosis standards in gynecology.

It is no hyperbole to describe a 2-10% incidence of missed cancers as being “seismic”—as some gynecologists have charged.

After all, they argue, the Yale numbers mean that 90-98% (i.e., the vast majority) of women do just fine in the hands of their gynecologists. But in fact, this is both a gross miscalculation and a terrible misrepresentation on the part of these physicians. A miscalculation, because the 2-10% of women with symptomatic uterine disease, at risk of having their potentially curable cancers inadequately or inappropriately treated, likely represent a far greater proportion of all the women who have gynecological cancers. And, a misrepresentation, because the harm resulting from gynecologists missing these cancers is totally avoidable—certainly, nowhere does majority benefit justify harm to a minority subset of women, on the order of 2-10%.

Considering that well over 500,000 American women undergo uterine surgeries in the United States alone, the number at risk of being inadequately or inappropriately treated for cancer by their gynecologists is well over 10,000 women per year. This is a simply an astonishing number of women in harm’s way—and, it is an undeniable fact, that the cost of this harm is to the integrity of families across the nation, and to our federal and private health insurance investments.

Very certainly, symptomatic uterine fibroid tumors are the only tumors with malignant potential in the human body, which are NOT subjected to ANY pre-operative biopsy screening for risk stratification by gynecologists.

This unsafe practice pattern is a radical departure from the standard-of-care in every other surgical specialty, in which tumors and tissues with malignant potential are ALWAYS subjected to stringent tissue biopsy, in order to risk stratify the patient—and are ALWAYS resected en bloc with good margins.

It is quite clear that gynecological leaders have failed to protect women from iatrogenic harm. The “how-and-why” of this failure relates to serious deficits in gynecological training, which is beyond the scope of this letter.

Notwithstanding, the imminent CDC focus on bringing gynecologists to safety in the cancer space, using multi-disciplinary guidance, is critical to protecting the lives of unsuspecting American women.

Change is coming to gynecology—and soon.

It is my hope that The Cancer Letter, and other prominent press outlets, will continue their detailed focus on this dangerous problem in gynecology, which will definitively save thousands of lives—when resolved by the CDC.

With this letter, for the historic record and to inform colleagues and CDC regulators, I am respectfully proposing the following four-point guidance to all gynecologists in their management of symptomatic uterine disease:

  1. Every symptomatic woman, considered a candidate for partial or complete uterine resection (a.k.a. Hyster-ectomy), should undergo both cervical and endometrial biopsy evaluation to rule out the presence of atypical cells or cancer. If an abnormality is found, the woman should undergo an oncological resection—preferably by a gynecological oncologist.

  2. Every symptomatic woman over age 55, considered a candidate for complete or partial uterine resection (a.k.a. Hyster-ectomy), should undergo a hysteroscopic endometrial biopsy to directly identify and biopsy any abnormal endometrial tissue present. If an abnormality is found, the woman should undergo an oncological resection—preferably by a gynecological oncologist.

  3. Every symptomatic woman with uterine fibroid tumors, considered a candidate for complete uterine resection (a.k.a. Hyster-ectomy), should undergo an oncologically safe operation—in order to avoid the intracorporeal disruption, disintegration or morcellation of these potentially malignant tumors.

  4. All symptomatic women with uterine fibroid tumors, who wish to maintain their fertility using a myomectomy, should undergo careful pre-operative tumor biopsy – specifically including core needle biopsy of their target tumor(s), as well as, careful endometrial and cervical sampling to rule out atypical cells and cancer. If any abnormality is found, the woman should not be offered a uterine-sparing operation and should instead undergo an oncological resection to prevent the spread and upstaging of cancer.

Adoption of these four cogent practice guidelines will almost certainly lead to detection and appropriate treatment of a vast number of the “missed” cancers demonstrated by the Yale study. 

Additionally, as reflected in the above criteria, only women who are candidates for a uterine sparing myomectomy, are the ones in whom a fibroid biopsy is absolutely required—in order to establish a “reasonable certainty of benignity” before subjecting the patient to what is a definitively non-oncological operation used to preserve fertility.

Needless to say, I am repeatedly surprised by the gynecological claim that uterine fibroid tumors cannot be biopsied with adequate sensitivity or technical feasibility. I know this claim to be a red herring used by those who wish to sustain the dangerous status quo in gynecology.

Most reasonable and seasoned pathologists, surgical oncologists and interventional radiologists would agree that biopsy of tumors with malignant potential, irrespective of any limitations due to sensitivity, sampling error, or technique is definitively feasible, and far safer than assuming benignity—as most general gynecologists have for decades in their management of symptomatic uterine fibroid tumors.

Finally, I offer you this letter and the four proposed guidelines, with hopes that cogent leaders in gynecology and at the CDC are able to recognize their merit and adopt them to steer the specialty to safety.

So that no other women fall to disaster as did Dr. Amy Josephine Reed of Yardley, PA.

Copyright (c) 2018 The Cancer Letter Inc.