A Critique of Professor Ted Anderson, President of The American College of Obstetrics and Gynecology — and Colleagues.
Honorable Professor Anderson,
I watched your recent roundtable discussion on management of uterine fibroid tumors with Professors Bradley, and Sanfilippo carefully.
This discussion can be viewed HERE.
This open letter of critique is to express total astonishment at what is a striking omission on your part as leading American gynecologists with expertise in the management of uterine fibroid tumors — and as the current president of ACOG.
Specifically, nowhere in your roundtable discussion about the diagnosis and management of symptomatic uterine fibroid tumors did you make, even an indirect mention of the fact that symptomatic fibroid tumors harbor a one in 200–500 probability of being malignant.
Of course, by most reasonable measures, this frequency of malignancy is quite sizable — especially considering the high prevalence of uterine fibroid tumors, as you well know.
Many colleagues and advocates are aware that this is a terrible and disturbing omission on your part as the specialty’s leaders. Foremost because the consequence of a general GYN missing the patient’s sarcoma diagnosis (or not having a high enough index of suspicion on pre-op evaluation) can be totally catastrophic to the at-risk subset of these patients.
Dr. Anderson, in your roundtable discussion, you repeatedly stated “treat the whole patient, not just the fibroid” and “the eyes do not see, what the mind does not know”.
Let me, respectfully, share with you that the way you are thinking about the possibility of malignancy in these symptomatic tumors is, indeed, blinded to a catastrophic problem in a minority subset of patient who present to you with “symptomatic fibroids”. But this minority subset, in actuality amounts to thousands of women every year, given the prevalence of what are known as uterine fibroid tumors and given the vast number of operations your specialty performs in the US and across the world. As you know, literally millions of women each year undergo hysterectomy or myomectomy operations.
I firmly believe that your roundtable discussion is, in fact, demonstration of how the specialty of GYN misses uterine soft tissue malignancies based on a utilitarian cognitive algorithm that is blind to a catastrophic miss in upwards of one in 200–500 unsuspecting women — at the highest academic and leadership levels of the gynecological specialty, as you and your roundtable colleagues represent.
I’ve pondered why you (and a vast majority of your general GYN colleagues) might be going down this path of cognitive dissonance (and downplay) when it comes to the malignant potential of uterine fibroid tumors.
Here is a detailed list of explanations to the sources of your error, because I cannot fathom that it is deliberate/intentional negligence driving you and your colleagues’ relative or total blindness to this catastrophic iatrogenic cancer risk in women:
1) Perhaps you do not believe the upwards of one in 200–500 incidence of a soft tissue sarcoma in women with symptomatic uterine fibroid tumors. Perhaps you believe this risk to be far lower — as your colleague UCLA Professor William Parker and friends have promoted. But, most reasonable clinicians and public health experts now agree that the literature, at this point in time, is convincing from multiple independent researchers and nations. Certainly FDA and CDC seem to have grasped that the incidence of cancer is NOT negligible in uterine fibroid tumors — and have confirmed an incidence of one in 200–500. Nonetheless, one wonders, is there a magical frequency of malignancy, where you believe missing a cancer diagnosis is ethically justifiable? Let us say if it’s one in 10,000 women, harboring sarcoma, is then missing a diagnosis a justified price of doing good for the majority? Of course this calculus is defunct, Dr. Anderson, as I hope you are able to see clearly.
2) Perhaps you do not believe that proper surgical handling (i.e., careful en bloc resection) of these cancers would change the prognosis and outcome for the patient. Indeed, how many times have I heard a GYN state to me on hearing about the death of my wife (and many others), “Sorry, but the long term outcomes for uterine soft tissue sarcoma are very poor anyway”. I find this particular defense of morcellation and the specialty’s “assumption of benignity” by gynecologists to be quite disturbed. Of course, this line of reasoning goes in the face of EVERY principle of surgery and surgical oncology known to ALL other surgeons and oncologist — whether or not they have the courage to voice their opinions with integrity and courage to save lives. Please accept that proper surgery on appropriately diagnosed cancers, and especially sarcomas, saves lives and buys invaluable time for the patient and her family — this is a clinical fact, Professor Anderson.
3) perhaps you will claim that in your roundtable discussion on symptomatic uterine fibroid disease, your focus was not oncological management — and that you, in fact, do have cancer in mind when evaluating these women. Unfortunately, it is exactly in the pre-operative evaluation and management of symptomatic uterine fibroid tumors by the general GYN that the cancer concern ought to be dominant in your minds. Because the pre-operative evaluation step is where these diagnosis are being “missed” or delayed by general gynecologists.
4) perhaps you believe that using size and number of fibroids, alone, as the exclusion criterion in deciding on open/en bloc surgery vs. MIS (i.e., with morcellation) is sufficient to rule out these cancers with acceptable precision. If this is the case, why not mention it in your roundtable discourse? Or is it that you recognize how that criterion, alone, is highly problematic in ruling out a malignancy? And the disturbing question persists, why do GYNs not rely on tissue biopsy to achieve reasonable certainty that these tumors are benign, before subjecting their patients to non-oncological (and oncologically catastrophic) uterine operations?
In the final analysis, I believe that your roundtable discussion clearly demonstrates how and why a vast majority of general GYNs are making the “assumption of benignity” about symptomatic uterine fibroid tumors — literally or functionally.
Dr. Anderson, when GYNs make a diagnosis of malignancy AFTER they subject women to non-oncological hysterectomy or myomectomy operations, it is, clearly and definitively, too late.
It is clear that because your primary objective is to eliminate bleeding and pelvic symptoms in these patients, because the vast majority of your patients do not have a soft tissue sarcoma, and because hysterectomy and myomectomy operations are amenable to driving profitable service lines at large medical centers, your specialty has been driven to a state of cognitive dissonance about the malignant potential of these tumors — in a minority subset of patients.
But this downplaying (or, in the case of your roundtable discussion with Drs. Bradley and Sanfilippo, total ignorance) of the one in 200–500 risk of soft tissue malignancies in your symptomatic patients is NOT justified — because the consequence of missing these cancers during pre-operative evaluation (or even intra-operatively, when you fail to send biopsy samples) is catastrophic to the subset of women whose cancers your specialty has a high likelihood of then spreading and upstaging — not to mention the delay in cancer diagnosis in these women, while you play around with various conservative treatments to stop the bleeding before offering your operations.
It is precisely because missing a uterine cancer diagnosis can be so catastrophic to the life of the at-risk woman that, despite the less than 1% risk, you must be overtly concerned with missing these diagnoses.
After over 5 years of wrestling with this terrible error in Gynecological practice and thinking, which caused the death of my wife, I am convinced that because hysterectomy/myomectomy operations are profitable and utilitarian in nature, there is no real impetus for GYN practitioners and leaders like yourself to think critically about the harm and injustice done to the minority subset of patients whose fibroids are in fact malignant and are being missed at the pre-operative stage of treatment — particularly when these women’s cancers are then treated in a delayed fashion or are iatrogenically upstaged. Indeed, professor Anderson, “the eyes do not see, what the mind does not know (or accept)”.
Additionally, I know that the resistance to changing your practices deliberately and effectively, so as NOT to miss these uterine soft tissue malignancies in a minority subset of women, will require a rather broad and seismic shift in your specialty’s thinking and utilitarian service line practices. Because of this, none of you have the stomach or courage to champion the change.
Who wants longer hospital stays, bigger incisions, longer operative times, more deliberate pre-op work-up and biopsies — more work and less revenue? No one!
But, I assure you professors, that there have been times in the past when ethically blinded utilitarian economics have been unjustifiably harming and damaging minority subsets of people in other domains of human activity, professions (including in medicine) and in society at large.
But precisely at those times real and ethical leaders have used their power and influence to fight wrongs and to do justice, to correct wrongs and to disrupt ethically unhinged utilitarian practices, in order to move society and institutions to operate in accordance with the principles of ethics, justice and decency — to create ethical utilitarian practices and institutions — where we do not sacrifice the lives of minority subsets of people, simply because what we do is somehow beneficial to the majority, real or perceived.
Dr. Anderson, your are the current president of ACOG. Dr. Bradley, you are the medical director of AAGL. And you both are experts in the management of symptomatic uterine fibroids at prominent Medical Center in our nation.
Please know that this email message to you is a warning and a call to integrity and action, for the historic record. Do not underestimate the meaning of the troubling omission from your roundtable discussion. It has, quite transparently, demonstrated the serious deficit in gynecological thinking about the management of symptomatic uterine fibroids, all of which harbor a deadly malignant potential. Your expert roundtable discussion is proof of why GYNs have been and are continuing to “miss” many uterine soft tissue malignancy diagnoses in women, preoperatively. Your tendency to “assume benignity” in the case of symptomatic uterine fibroids is a serious, specific and deadly systemic error in clinical judgement. And the cost of this failure is to one in 200–500 women, whose cancers are at risk of being “missed” and catastrophically, iatrogenically upstaged — this is NOT a mortality risk you can neglect.
Indeed, “the eyes do not see, what the mind does not know (or accept)”, Dr. Anderson: Uterine fibroid tumors have a malignant potential that cannot be neglected preoperatively by general gynecologists — because the measure of how great you are is not how much revenue your service lines generate and how many patients you move along your conveyor belts “uneventfully”. It is rather how many lives you save at the extremes of your practice where specific dangers lurk.
But, perhaps, you do not see. I hope that you will.
I look forward to your response.
Very sincerely,
Hooman Noorchashm MD, PhD (For Amy and the others).
