BJOG on the case: morcellation
To morcellate or not to morcellate – is that the question? BERTIE LEIGH, FRCOG ad Eundem, SENIOR PARTNER, HEALTHCARE LAW DEPARTMENT, HEMPSONS, UK
.................................................................................................................................................................. The row over morcellation of apparently benign tissue has generated understandable concern from patients whose previously undiagnosed sarcomas have been upstaged to Stage 4 as a result of being spread about the peritoneum to facilitate the removal of their fibroids (www.change.org/ petitions/women-s-health-alertdeadly). The concern of the oncological establishment to defend minimally invasive surgery is also understandable (Goff BA, Lancet Oncol 2014;15: e148), but how should they deal with the proposition that “Guidelines should err on the side of caution where hazards are reported”? (Editorial, Lancet Oncol 2014;15:123). The problem facing patients is that large fibroids and ovarian cysts cannot be removed through 1 cm incisions. If they opt for open surgery their funder must pay more, they must accept longer recovery, larger scars and greater risks of adhesion-related pain. In the present state of the art, doctors cannot confidently exclude sarcomas pre-operatively. They may be more suspicious where the fibroid first presents perimeno-
© 2015 Royal College of Obstetricians and Gynaecologists
pausally (Reed N, Curr Oncol Rep 2013;15:581–7) and expands rapidly, causing pain or abnormal bleeding, especially with cystic spaces on imaging. In the hands of sub-specialists the risk must be much less than the headline figures based on simple incidence suggest, but it cannot be excluded. The properly counselled woman has no easy options. If the problem is presented in overly cautious terms, some women under 30 with no risk factors will sensibly decide that their symptoms are not so severe that they wish to accept the adhesion pain and the scar associated with open surgery and will choose to grin and bear it. Most benign gynaecology is carried out to relieve symptoms. A very few of women will thereby avoid the morcellator upstaging of their leiomyosarcoma. Unfortunately, most of them will re-present when their malignant condition has progressed due to the natural history of the disease. If the advice they were given erred on the side of caution, they may have cause for complaint, as will their sisters presenting for repeated unsuccessful adhesiolysis. Some may be offered treatment by
embolisation or MRI-focused ultrasound. Is that good therapy for fibroids with lurking sarcomas? Nobody knows: some sarcomas have presented after such treatment, but how many have been infarcted and cured? I have three suggestions: 1 2
3
Leave the mode of surgery to the surgeons. Leave the decisions to the patients because they are the ones who have to live or die with the consequences. Recognise your responsibility to provide patients with clear and balanced information about all aspects of the proposed procedure. This does not mean erring on the side of caution in a world with risks on every side. Where some patients may be interested in a rare problem, a leaflet or electronic decision aid may be useful and can provide a record of what you have said. (Stacey D, Bennett CL, Barry MJ, et al. Cochrane Database Syst Rev 2011;(10): CD001431).
Disclosure of interests None. &
461
To morcellate or not to morcellate – is that the question? BERTIE LEIGH, FRCOG ad Eundem, SENIOR PARTNER, HEALTHCARE LAW DEPARTMENT, HEMPSONS, UK
.................................................................................................................................................................. The row over morcellation of apparently benign tissue has generated understandable concern from patients whose previously undiagnosed sarcomas have been upstaged to Stage 4 as a result of being spread about the peritoneum to facilitate the removal of their fibroids (www.change.org/ petitions/women-s-health-alertdeadly). The concern of the oncological establishment to defend minimally invasive surgery is also understandable (Goff BA, Lancet Oncol 2014;15: e148), but how should they deal with the proposition that “Guidelines should err on the side of caution where hazards are reported”? (Editorial, Lancet Oncol 2014;15:123). The problem facing patients is that large fibroids and ovarian cysts cannot be removed through 1 cm incisions. If they opt for open surgery their funder must pay more, they must accept longer recovery, larger scars and greater risks of adhesion-related pain. In the present state of the art, doctors cannot confidently exclude sarcomas pre-operatively. They may be more suspicious where the fibroid first presents perimeno-
© 2015 Royal College of Obstetricians and Gynaecologists
pausally (Reed N, Curr Oncol Rep 2013;15:581–7) and expands rapidly, causing pain or abnormal bleeding, especially with cystic spaces on imaging. In the hands of sub-specialists the risk must be much less than the headline figures based on simple incidence suggest, but it cannot be excluded. The properly counselled woman has no easy options. If the problem is presented in overly cautious terms, some women under 30 with no risk factors will sensibly decide that their symptoms are not so severe that they wish to accept the adhesion pain and the scar associated with open surgery and will choose to grin and bear it. Most benign gynaecology is carried out to relieve symptoms. A very few of women will thereby avoid the morcellator upstaging of their leiomyosarcoma. Unfortunately, most of them will re-present when their malignant condition has progressed due to the natural history of the disease. If the advice they were given erred on the side of caution, they may have cause for complaint, as will their sisters presenting for repeated unsuccessful adhesiolysis. Some may be offered treatment by
embolisation or MRI-focused ultrasound. Is that good therapy for fibroids with lurking sarcomas? Nobody knows: some sarcomas have presented after such treatment, but how many have been infarcted and cured? I have three suggestions: 1 2
3
Leave the mode of surgery to the surgeons. Leave the decisions to the patients because they are the ones who have to live or die with the consequences. Recognise your responsibility to provide patients with clear and balanced information about all aspects of the proposed procedure. This does not mean erring on the side of caution in a world with risks on every side. Where some patients may be interested in a rare problem, a leaflet or electronic decision aid may be useful and can provide a record of what you have said. (Stacey D, Bennett CL, Barry MJ, et al. Cochrane Database Syst Rev 2011;(10): CD001431).
Disclosure of interests None. &
461
