Boston surgeon, physician wife campaign against procedure
A Boston surgeon and his wife, an anesthesiologist, are pushing to stop a widespread surgical technique used on thousands of women during hysterectomies, which they say caused her undetected cancer to dangerously spread.
Dr. Hooman Noorchashm, a cardiothoracic surgeon at Brigham and Women's Hospital, has started an online petition and written dozens of letters to medical journals and media organizations charging that the technique, called "morcellation,'' is endangering women and creating a public health crisis. He has adamantly demanded that his own hospital — where his wife's operation was performed — stop using the procedure, and called on other hospitals and doctors nationwide to do likewise. It is typically employed during laparoscopic hysterectomies, a type of minimally invasive surgery.
"This is a very ethically black and white issue,'' Noorchashm said. "One of your own got it. Stop doing it at the Brigham at least, and encourage others to stop doing it.'
The hospital has made some changes, including recommending against morcellation for certain women who are more likely to have undetected cancer, but will continue to use the procedure.
Leaders at the Brigham and a number of other organizations nationally said that the risk of spreading unknown uterine cancer is low, and that in many cases, particularly for younger women, it is outweighed by the benefits of removing the uterus laparoscopically, without major surgery. But some are starting to raise cautions about the procedure.
Noorchashm began campaigning against the procedure after his wife, Dr. Amy Reed, a physician at Beth Israel Deaconess Medical Center, and their family were hit with personal tragedy.
Reed, 40, underwent a hysterectomy in October at the Brigham to treat what she was told were likely benign fibroids, or masses, in her uterus. During the laparoscopic procedure, the gynecologist used a morcellator to cut her uterus and the fibroids inside into small pieces so they could be taken out through the tiny incisions used in minimally-invasive surgery.
Follow-up tests done on the tissue found that Reed had uterine leiomyosarcoma, a rare aggressive cancer. Later imaging tests showed that the cancerous tissue had been spread throughout her abdominal cavity during the surgery, giving her stage 4 cancer, her husband said. He said she also has nodules on her lungs that doctors are watching and they are unsure if those are cancer. The Brigham said it is not overseeing Reed's follow-up care, so cannot comment on her current condition.
The couple has six children between the ages of 1 and 12.
Reed is undergoing chemotherapy and is now recovering from major follow-up surgery at another hospital to remove cancerous tissue. She said in an interview Tuesday that she is lucky to "have a lot of family support'' but "it's been incredibly difficult for all of us. There is no reason women should be going through this.''
Reed said the gynecologist at the Brigham who did her hysterectomy did not inform her of the risk that morcellation can spread cancer. The hospital agreed with this characterization in a statement, though it said the doctor did disclose a remote risk of the fibroids being cancerous.
The Brigham, which uses morcellation in about 200 gynecological surgeries a year, said it won't stop using the procedure because it is the standard of practice, as recommended by national groups such as the American Congress of Obstetricians and Gynecologists and the American Association of Gynecologic Laparoscopists.
The Brigham did issue formal guidelines to doctors this month on when morcellation should and should not be used
The hospital is recommending against the procedure in women with any evidence of cancer or in women over 45, who have large uterine masses and heavy menstrual bleeding, who might be more likely to have hidden cancer.
In a letter sent to Brigham medical staff on Dec. 5, Obstetrics and Gynecology Chairman Dr. Robert Barbieri urged doctors to talk with patients about the small risk of spreading cancer through morcellation, which he said may occur in as many as 1 in 400 cases.
"We reiterated this is something we are keeping an eye on. We want doctors to be explicit,'' he said in an interview.
Morcellation also may impede later efforts to evaluate the tissue to determine the presence or scope of cancer, Barbieri wrote in the letter.
"An alternative to morcellation is the intact removal of the uterine tumor or uterus through an abdominal incision," he wrote. "An abdominal incision creates a larger scar, and is associated with a higher risk of skin infection and a longer period of recovery. However, if the uterine tumor is a cancer, there is minimal risk of spreading the malignancy or compromising the pathological diagnosis."
The Brigham said in a statement that "while it's not possible to know what impact the procedure will ultimately have on Dr. Reed's health, we do know that literature suggests morcellation of malignant tumors increases the chances of mortality. All involved in Dr. Reed's care are deeply saddened by the news of her illness.''
About 600,000 hysterectomies are done in the United States every year, most done to treat benign fibroids using minimally invasive techniques. Morcellation is not generally recommended for use in patients who are known to have cancer. But there is no definitive diagnostic test for leiomyosarcoma.
Such sarcomas are rare, aggressive, and have a high rate of recurrence even in woman who have not undergone a morcellation, said Dr. Barbara Goff, president of the Society of Gynecologic Oncology and director of the Division of Gynecologic Oncology at the University of Washington in Seattle.
Morcellation allows many women to have safer hysterectomies with better outcomes than full abdominal surgery, including less blood loss, smaller wounds, and a quicker overall recovery, Goff said.
"You try to balance cost and outcomes and doing the best you can for an entire population of women," Goff said.
But Dr. Bobbie Gostout, chairwoman of obstetrics and gynecology at the Mayo Clinic, said more women should be given the option of a vaginal hysterectomy, where the uterus can often be taken out intact through the vagina, especially because morcellation "is a questionable practice."
She said morcellating devices are not yet good at capturing tissue or protecting other sensitive organs from rotating blades.
"I don't want to see [morcellation] go away, but I would like to see it kept in perspective and occupy its necessary place," she said. "Morcellation is still so far off what it ought to be."
Noorchashm said he believes doctors and hospitals such as the Brigham are still using the procedure because it allows them to do more procedures faster, which is more profitable.
"There is a lot of money involved in this business,'' he said.
The Brigham said this is not a factor and that insurers pay more for open abdominal surgery because it requires longer hospital stays.