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How Often Does Morcellation Involve Cancers other than LMS?

A recent article in the Journal of the American Medical Association (JAMA) reported that the rate of uterine cancer among women having surgical procedures using morcellation was 1 woman out of 368. Since the recent FDA hearing was about morcellation and the risk of finding uterine leiomyosarcoma (LMS), some of the media have misinterpreted this number to mean that 1 out of 368 women who had a morcellation procedure were found to have a LMS.

The authors reviewed 6 years of data from an insurance company’s database of 500 hospitals and found 36,470 women who had procedures with morcellation during that time. Then they determined how many of these women had a final diagnosis of any type of uterine cancer. Over the 6 years, 99 of the 36,470 women were found to have any kind of uterine cancer. However, the authors did not determine how many of these women had leiomyosarcomas and how many had the more common (and usually less dangerous) types of uterine cancers such as uterine lining cell cancer.

The US Center for Disease Control (CDC) states that uterine lining cell cancers make up 97% of all uterine cancers, and uterine leiomyosarcomas (LMS) make up about 2-3% of all uterine cancers (other uterine sarcomas are even more rare). If we apply these percentages to the JAMA study, and we do the math, then 3% of the 99 cancers found in the JAMA study means 3 women with LMS were found among the 36,470 women who had morcellation. That means 1 woman with LMS for every 12,279 women (0.008%) who had morcellation. This number is even lower than the rate calculated in Dr. Pritts’ study (see earlier post)¬†and is much lower than the rate calculated in the sub-optimal analysis done by the FDA, which calculated a risk 27 times higher.

Nevertheless, gynecologists and women who are considering hysterectomies with morcellation may have something important to learn from the JAMA study. If 96 cancers of the uterine lining (endometrial cancer) were not detected or suspected prior to surgery, then gynecologists may not be doing the best job of evaluating women with this disease, or our current testing methods are not working very well. While we currently do not have a way of detecting LMS before surgery, we do have ways to detect uterine lining cell cancers before surgery. Many women with fibroids have heavy vaginal bleeding with their periods. Many women with uterine lining cell cancer have irregular bleeding before menopause or have bleeding after menopause when bleeding is supposed to have stopped. If women have irregular bleeding, we have ways to detect uterine lining cancer in the office.

Trans-vaginal pelvic ultrasound can measure the thickness of the uterine lining fairly accurately and MRI, while more expensive, is also very accurate to measure the lining cell thickness. If the lining is normal thickness (“normal” will depend on whether you are pre-menopausal or post-menopausal), then the risk of having uterine lining cancer is very, very small. If the lining measures thicker than normal, the causes may be benign polyps, a fibroid inside the uterine cavity, benign overgrowth of the lining cells (benign hyperplasia), pre-cancer of the uterine lining cells (atypical hyperplasia) or uterine cancer.

If the lining is thick, then the next step is either an endometrial biopsy in the office or a full D&C, often in an outpatient surgery center. Both of these procedures remove lining cells for analysis by the pathologist, and both are very accurate, although not quite 100%. The unanswered question raised by the JAMA article is whether gynecologists are not appropriately evaluating women for uterine lining cancers before hysterectomies or whether ultrasound, MRI, endometrial biopsy and D&C do not detect these cancers as well as we thought.

We obviously need more research to find a way to diagnose leiomyosarcomas before surgery – this should be one critical outcome of the current FDA hearing. We also need to heed this study as a call for gynecologists to consider the diagnosis of uterine lining cell cancer more often and make sure we do the proper testing before surgery, and certainly before morcellation. If you have questions about whether you should have testing for uterine cancer before surgery, ask your doctor to discuss this with you.

Next post: Why not biopsy fibroids to make sure they are not cancer?

 

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Disclaimer: The ideas, procedures and suggestions contained on this web site are not intended as a substitute for consulting with your physician. All matters regarding your health require medical supervision.

Fibroid Doctor William H. Parker

Dr. William H. Parker is a board-certified Fellow in the American College of Obstetricians and Gynecologists. Dr. Parker is an internationally recognized expert in fibroid surgery and research. Based in San Diego, California, he is considered one of the best fibroid surgeons for abdominal and laparoscopic myomectomy in the United States and abroad. He has been chosen for Best Doctors in America and Top Doctors every year beginning in the late 90's.

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