Morcellation: Doctors Need Data, Not Rhetoric

This is my first foray into the “blogosphere” and as such, let’s set some ground rules. This is not a scholarly treatise and will have no footnotes, annotations, or references. Further, this screed in no way represents the views of my employer; it’s simply my opinion. Finally, place as much importance to whatever follows as you would the ranting’s of Howard Beale….

Much has been discussed over the past six months regarding the issue of “mechanical power morcellation.” In fact, in my 25 years of clinical practice, I have never seen such a rapid and visceral outcry against a device or procedure. What follows are a few thoughts as I run off at the keyboard…

#1

I do not believe it is overstating the obvious when I say we all, any doctor who has had a patient with a sarcoma of any kind, feel great sorrow and compassion for Drs Amy Reed and her husband, Hooman Noorchashm. (I use their names here only in light of the fact that they have openly discussed their health issues in the lay press…No HIPAA issues here.) We all know that sarcoma is a “bad actor” regardless of its stage at initial presentation. I wish them nothing but the best outcome and have actually included them in my prayers. That said, it appears that Dr Noorchashm is ensconced in the Kubler-Ross “anger” stage of grief. He is lashing out, understandably, but that is no excuse for railing against procedures and techniques that benefit thousands of women.

#2

Denigrating an entire surgical specialty as Dr Noorchashm has done is not going to win friends or influence people. He has publicly cast aspersions at gynecologists nationwide, calling into question our training and motives. Agreed, we do train in “silos” as he likes to say, but our skills and expertise are well-honed to our patient’s needs. He is flabbergasted that we morcellate tissue in the normal course of events. The reason, I believe, is thus: the vast majority of masses we find in the female pelvis are benign. That is not the case in the mediastinum or retroperitoneum. It’s entirely appropriate to tailor our procedures to our patients and their pathology.

Further, Dr Noorchashm has proposed that we as GYN surgeons have a financial incentive to use mechanical morcellation. Really? Has he been through a recent medical coding course? I can make more money per case with open hysterectomy and myomectomy. I can complete the case in 60 minutes, charge more, and have the residents round on her for three days. I use the morcellator to benefit the patient, not me. She is out of the hospital the same day and back to work in days, not months. I would be very interested to see how he believes that we have a financial benefit.

#3

The major sticking point I have discovered as I discuss this issue with my colleagues is as follows: where are these sarcoma patients? I have been in practice over 25 years and have never, NEVER had a sarcoma morcellated. I have had discussions with scores of GYN surgeons, and they report the same. I have reviewed with our pathology department our data over the past 10 years. Three thousand cases and not one morcellated sarcoma. (There were three endometrial carcinomas, all in patients with prior negative endometrial biopsy, however.)

We have been quoting to our patients a 1/10,000 risk of sarcoma for decades. Where does this 1/350 number come from that the FDA and Noorchashm put forth? Is there a previously unidentified sarcogenic adulterant in the Boston water supply? Why is the reported incidence at Brigham Women’s so out of line with everyone else’s experience? Selection bias? Are patients lost to follow up? Regional variation? Of course, we all want to quote accurate information to our patients as we obtain informed consent; so what is it? 1/10,000 or 1/350? Or some number in between? We need, and our patients deserve, an answer.

#4

If we ban morcellation, do we doom thousands of women to open procedures? No one can deny the benefit of minimally invasive surgery. But will a ban of mechanical morcellation limit access to MIGS? Honestly, this is not a game changer for me. I have performed hundreds of cases prior to the advent of mechanical morcellators and I will be just fine without them. My fear is that surgeons with less experience will simply throw their arms to the air and revert back to open cases. MIGS is much safer than open. It’s analogous to grounding air travel in light of an incident: No one will die in the air, but scores more will die on the ground.

And lets take this a step further. If we can’t morcellate a fibroid because it may be a sarcoma, how do we justify the conservative management of fibroids? Does this mean that we can’t observe serial sonos? Can’t use OCPs or Lupron? Can’t offer UAE or other noninvasive options? Really? Because that is great for my surgical volume. I can now say with a clear conscious, “The FDA thinks that you have a 1/350 chance of cancer, so lets go to the OR.” If Noorchashm is looking for a financial angle in this story, it lay here.

Bottom line: I feel for Amy and Hooman, but we must not let the tail wag the dog here. We sorely need data. Are we dealing with a 1/10,000 occurrence, akin to a lightning strike, or a 1/350 incidence, in line with hip fracture risk? No doctor wants to put his or her patient at undue risk. Lets simmer down the rhetoric and allow cooler heads to prevail. Hard cases make bad law.