July 23, 2014
News Review From Harvard Medical School -- Study Tallies Cancer-Spread Risk of Procedure
A study has provided new estimates of the risk that one surgical technique to remove the uterus might spread an undetected cancer. The study looked at morcellation. This technique uses a power cutter to slice the uterus into tiny pieces. Sometimes hysterectomy (removal of the uterus) is done through several small incisions instead of one large incision. The surgeon views the area through a tool called a laparoscope. Cutting up the uterus with morcellation allows removal through the small incisions. But in some cases, undetected cancers have been cut up at the same time. This has allowed cancer to spread to other organs. In April, the Food and Drug Administration discouraged use of this procedure. The new study looked at insurance data for 230,000 hysterectomies. All were done using the less invasive procedure with small incisions. About 36,000 used morcellation. From this group, 99 cases of uterine cancer later were found. That's about 27 women for every 10,000 who had morcellation. Cancers were quite rare for women under 40. The risk was higher for women older than 65. The Journal of the American Medical Association published the study. HealthDay News wrote about it July 22.
By Howard LeWine, M.D.
Harvard Medical School
What Is the Doctor's Reaction?
Minimally invasive surgery has improved outcomes for many surgical procedures. But a new report suggests that one minimally invasive technique may spread previously undetected cancer. This technique is used to perform a hysterectomy (removal of the uterus).
With minimally invasive surgery, the surgeon can make much smaller incisions (cuts). He or she inserts an instrument called a laparoscope into one small incision. Tools are inserted into the others. The doctor looks through the laparoscope to perform the procedure.
This type of surgery has dramatically reduced length of stay in the hospital compared with traditional surgery. If minimally invasive surgery occurs in the morning, the patient can often go home the same day. People can get out of bed sooner and often have less pain than with traditional surgery. And that decreases the risk of problems such as blood clots in the legs and pneumonia.
Hysterectomy (removal of the uterus) is one of the procedures that can be done using a laparoscope. The uterus is a muscular organ, normally the size of a small lemon. Many women have a hysterectomy because of benign (non-cancerous) growths called fibroids. These growths can make the uterus much larger. Removing the uterus through a small incision usually requires cutting it into small pieces.
A popular method used is called power morcellation. The morcellator is an electric power tool. It can easily cut up the uterus into small pieces. The pieces are removed through the small incisions.
The U.S. Food and Drug Administration (FDA) issued a safety alert about morcellation on its website on April 17. If the uterus being removed has cancer cells, morcellation can cause these cells to spread into the abdomen and pelvis.
A surgeon who suspected that the uterus or nearby organs contained cancer cells would never use morcellation. But it's not always possible to know for sure.
This research paper gives us some idea of the risk that morcellation of the uterus will spread cancer. In this study, for every 10,000 women who had the procedure, 27 were found to have cancer.
At first, this may sound scary. But, in fact, a woman who has morcellation of the uterus has a greater than 99.7% risk of not having cancer. Unsuspected cancers in younger women were extremely rare. The risk increased with age.
What Changes Can I Make Now?
There are several reasons why a woman may need to consider a hysterectomy. Fibroids are a very common condition. These benign tumors can become very large or there may be many of them. The result may be discomfort and irregular vaginal bleeding. Some women have very heavy periods that cause iron-deficiency anemia.
Multiple or very large fibroids may require a hysterectomy. But methods that don't involve surgery can be used to shrink fibroids. If surgery is needed, there are other options besides morcellation.
If you do need a surgical procedure for a problem with your uterus, be sure you understand why it needs to be done. Review the pros and cons of the different approaches with your doctor. This is the best way to arrive at the best treatment for you.
What Can I Expect Looking to the Future?
For the near future, I suspect that surgeons will rarely use power morcellation for hysterectomies. That's because there will almost always be another option. But we should keep in mind that the risk of spreading cancer by power morcellation truly is extremely small.