A Follow-up Public E-mail to Professor Ted Anderson, President of the American College of Obstetrics and Gynecology (ACOG): On the Danger of Uterine Morcellation Practices.
The e-mail copy enclosed below is a follow-up public warning message submitted to Dr. Ted Anderson, the current and 70th president of the American College of Obstetrics and Gynecology (ACOG) — and CC’d to the press, regulators and leading clinicians in Gynecology and in Oncology.
In Spring 2019, I sent my first public letter to Professor Anderson. You may read this letter by clicking HERE. I have not yet received a response from Dr. Anderson or his colleagues at ACOG.
From: Hooman Noorchashm
Date: January 2, 2020 at 9:54:37 AM EST
To: “Anderson, Ted L (University)” <ted.anderson@vanderbilt.edu>
Cc: O__@cdc.gov, “Briss, Peter (CDC/ONDIEH/NCCDPHP)” <p__@cdc.gov>, Alan Slobodin <Alan.Slobodin@mail.house.gov>, Brian Fitzpatrick <B_____@gmail.com>, “Knowles, Joseph” <Joseph.Knowles@mail.house.gov>, Peter Lurie <plurie@cspinet.org>, Michael Paasche-Orlow <Michael.Paasche-Orlow@bmc.org>, “Levitz, Jennifer” <Jennifer.Levitz@wsj.com>, “Kamp, Jon” <Jon.Kamp@wsj.com>, “mark.maremont” <mark.maremont@wsj.com>, “Grady, Denise” <grady@nytimes.com>, “Kowalczyk, Lizbeth” <lizbeth.kowalczyk@globe.com>, “Kowalczyk@globe.com” <kowalczyk@globe.com>, “Sutton, Charlotte” <CSutton@philly.com>, Matthew Ong <matthew@cancerletter.com>, Paul Goldberg <paul@cancerletter.com>, Nick Mulcahy <nmulcahy@medscape.net>, Jennifer Block <writingblock@gmail.com>, Emily Dwass <emilydwass@yahoo.com>, howard.bauchner@jama-archives.org, “Rubin, Eric” <erubin@nejm.org>, Nancy Chescheir <NChescheir@greenjournal.org>, president@rcog.org.uk, General Mail <GeneralMail@aagl.org>, Tom.Burton@wsj.com, Amy.Marcus@wsj.com, betsy.mckay@wsj.com, Jeff Shuren <Jeff.Shuren@fda.hhs.gov>, Richard Pazdur <Richard.Pazdur@fda.hhs.gov>, Michael Burgess <Lesley.Fulop@mail.house.gov>
Subject: A Second WARNING to ACOG President, Professor Ted Anderson of Vanderbilt UniversityProfessor Anderson,
I ask that in this New Year, you read my 2019 open letter to you again without professional ego guiding you.
I am compelled to write you here again, as I’ve had an opportunity review ACOG’s Committee Opinion 770 in its entirety now. This guideline document is a radically flawed and dangerous work-product of ACOG, which not only serves to underplay the risk of “missed” uterine soft tissue malignancies, it will almost certainly cause further harm to the women whose uterine sarcomas will continue to be “missed and morcellated” by Gynecologists with catastrophic consequences.
I ask that you consider the following risk analyses and analogies, when you deliberate on my statements in this email: HERE and HERE.
https://medium.com/@noorchashm/the-power-morcellator-in-gynecology-medicines-ford-pinto-fb3dd4013278
As, US congressman and Gynecologist, Dr. Michael Burgess said on the congressional record in 2015, “every doctor who operates in the abdomen knows that if there is a stage 1 encapsulated tumor, and you disrupt the capsule, you’ve changed it from a stage 3 or a stage 4 process. Fibroids, Leiomyomtomas, by definition are almost all benign tumors. But almost does not mean all.”
https://www.youtube.com/watch?v=1to_Am94pnU
You may read my recent letter to congressman Burgess, requesting that the US House of Representatives now formally query ACOG regarding its Committee Opinion 770, HERE.
The specific reasons it is critical for ACOG to be publicly interrogated regarding its current recommendations on morcellation of potentially malignant uterine tumors are the following:
1) there is an unacceptable disparity in the risk estimate on uterine sarcomas, used by ACOG (One in 770–10,000) versus that of FDA and several other highly reputable academic institutions across the nation (One in 200–500). This represents a systematic attempt at misleading the public and GYN practitioners, on the part of GYN industry advocates, like Dr. Parker, Pritts, J. Brown and others.
2) Nowhere in ACOG Opinion 770 is it reflected that, in addition to uterine soft tissue malignancies, General GYNs are “missing” other uterine cancer diagnoses (i.e., endometrial and cervical) pre-operatively at an astronomical rate — and that the consequence of non-oncological operations or morcellation is equally catastrophic in the cases of other cancers when they are iatrogenically spread and upstaged. The work of Desai and Wright from Yale and Columbia are telling in this regard, as you well know.
3) Opinion 770 proposes that “shared decision making” (i.e., patient consent) somehow justifies exposing women to a very specific mortality hazard resulting from cancer upstaging by morcellation. This ACOG contention must be vetted carefully by ethics experts and justified, because it does not appear to pass bioethical or legal muster: Exposing a woman to a specific and avoidable cancer mortality risk cannot be justified when a physician whose tendency it is to downplay that risk is “informing” a woman whose tendency it is to trust that doctor’s judgement. “Salesmanship” and ethical “informed consent” are two entirely different practices, I am sure you understand.
4) ACOG appears to insinuate that the oncological mortality risk imposed on women by morcellation is negligible or acceptable because cancer, in general, and sarcomas in particular, have “a poor prognosis anyway”. Of course, nowhere does ACOG admit that cancer cures and enhanced prognoses, especially in the case of sarcomas, are achieved every day through en bloc and meticulous surgical resection of candidate tumors and organs. In fact, the ONLY hope for a cure or enhanced prognosis in the case of sarcomas specifically, is en bloc surgical resection, which morcellation entirely robs the affected women of.
5) It has been striking that nowhere in ACOGs deliberations has the notion that tissue biopsy can, in fact, provide the practitioner and the patient with a “reasonable assurance of benignity” before proceeding with a non-oncological operation — be this a myomectomy or an operation involving morcellation. ACOGs resistance to, or very superficial consideration of, this gold standard medical diagnostic approach to assessing the malignant potential of ANY tumor, as used by all other surgical disciplines, is a dangerous error and requires interrogation. Of course, the convenient gynecological tendency to conflate endometrial or cervical biopsies with biopsy of uterine soft tissue tumors in the public discourse on uterine cancers, is extremely concerning and disingenuous. Why are GYNs and ACOG so resistant to the idea of tissue biopsy of symptomatic uterine fibroid tumors before proceeding with a non-oncological operation?
Dr. Anderson, you are well aware that in the US hundreds of thousands of women are undergoing non-oncological uterine operations (i.e., hysterectomy and myomectomy) for symptomatic uterine fibroids each year. Across the globe the annual numbers will almost certainly be in the millions of women. “Missing and morcellating” uterine cancers in these women, and thereby iatrogenically upstaging their cancers, is no small global iatrogenic women’s health catastrophe. That it is an IATROGENIC catastrophe makes it amenable to immediate prevention — unlike other infectious disease and women’s health crises. It is because of this undeniable fact that ACOG’s weak and protectionist response, as encapsulated in Opinion 770, is so dangerously flawed and unacceptable: we should all work to prevent specific preventible mortality risks to people.
In your capacity as ACOG’s president, I am writing you for the record this second time — in order to seek ACOG’s accountability to the public in sustaining a uterine cancer mortality risk to American women. It is an untenable position for a specialty whose practitioners enjoy generous funding from many federal and private health insurance funds to not be held fully accountable, when it is highly likely that its professional practices are accepting and sustaining a severe, but avoidable, mortality risk to the lives of women.
Professor Anderson, in a prior email to me you used the word “endearing” to describe my efforts and writings aimed at creating a public record of ACOG and AAGL’s dangerous and erroneous handling of the morcellation hazard in uterine surgery. Your description was an incorrect and disturbing platitude. What I am doing here is to create a legally and ethically undeniable public record regarding a very specific and avoidable act of systemic negligence by your practitioners, by ACOG and by AAGL. I assure you that there is nothing “endearing” about the way in which this hazard of gynecological negligence kills the women who fall victim to it when their uterine cancers are missed and then spread in their abdominal cavities — in the US and abroad.
Every public health official, gynecological leader and regulator who is aware of this avoidable iatrogenic mortality risk to women, and who is not rising to eliminate it from the US healthcare space is culpable for complacency or negligence in their duties — I ask that you not take these words as hyperbole or an exaggeration. ACOG and AAGL behavior in this space is an historic example of industry protectionism, cognitive dissonance about a “standardize” negligent practice.
Your time window to lead as ACOG’s president and to demonstrate that ethics and reason can prevail in your specialty is coming to an end — do consider doing right by your patients and by your professional duty.
I write you, a second time and for the historic record.
Sincerely,
Hooman Noorchashm MD, PhD (For Amy and the others).
