Appeal to Intergroup for
Uterine Artery Embolization
What they say
Foundation Health Systems, Inc.
Position Statement: Uterine Artery Embolization for Treatment of Fibroids
Dated 10/08/98, with lines for approval signatures from Dr. Dale Berkbigler and Jacqueline Sandvik. My copy is not signed.
Section II. Introduction, wih my responses:
FHS: Transcatheter arterial embolization is an established and effective pelvic angiographic technique used to control acute and chronic pelvic bleeding for a variety of diagnoses outside the field of obstetrics and gynecology.
My response: Interventional radiologists have been embolizing uterine arteries to control acute bleeding of the uterus for the last 15 years. I am not sure how this falls outside the field of obstetrics and gynecology, since acute uterine bleeding is most likely to accompany childbirth. To quote from The Society of CV and Interventional Radiology Website (http://www.scvir.org/fibroid/index.htm):
While embolization to treat uterine fibroids has been performed for more than six years, embolization of arteries in the uterus is not new. The procedure has been used successfully by interventional radiologists in uterine arteries for more than 20 years to treat heavy bleeding after childbirth. Today, fibroid embolization is being performed at hospitals and medical centers across the country, in Canada and around the world. As of the end of 1998, about 1,500 to 2,000 fibroid embolization procedures had been done world-wide. (NRL note: I believe this number is now closer to 2,500.)
FHS: Uterine artery embolization for the treatment of uterine fibroids is a new application of the established transcatheter arterial embolization procedure. Researchers postulate that blood deprivation to the fibroid will result in shrinkage, decrease symptomatology (e.g., bleeding, and possibly pain), and may also allow woment to retain childbearing potential.
My response: Researchers do not postulate that blood deprivation will shrink fibroids; our experience is way past that point. Rather, current medical evidence demonstrates that blood deprivation shrinks fibroids. Likewise, researchers do not postulate that blood deprivation of fibroids decreases bleeding and possibly pain; rather, current medical evidence demonstrates that, for an average 89% of patients, UAE produces significant or total symptomatic relief. To quote again from The Society of CV and Interventional Radiology (SCVIR) Website:
The results of studies that have been published or presented at scientific meetings report that 78 percent to 94 percent of women who have the procedure experience significant or total relief of pain and other symptoms, with the large majority of patients considerably improved. The procedure has been successful even when multiple fibroids are involved ... The expected average reduction in the volume (size) of the fibroids is 50 percent after three months, with a reduction in the overall size of the uterus of about 40 percent.
Additionally: At the age of 47, childbearing is not the major issue for me, though Im loathe to allow an insurance company to make that decision for me. However, to set the record straight, Ill include another quote from the SCVIR:
The majority of patients who have fibroid embolization are finished with childbearing and few women have tried to subsequently become pregnant, making fertility difficult to study. More than a dozen pregnancies have been reported, however, and patients who have had uterine arteries embolized for other reasons, such as bleeding after childbirth, have successfully become pregnant.
My response:A body of evidence based on experience with 2,500 patients is not a small sample. And if long-term follow-up means more than 10 years, its a moot point in terms of my treatment. I am nearly 48 years old and menopause will manage my fibroid problem soon enough, if necessary. Six years durability has been proven, and six years durability is all that I require.
My response, objetive:The procedure in general is quite well-defined. Here is a description from the SCVIR Website:
My response, subjetive:The statements about angiographic technique and particle size comprise possibly the most ludicrous aspect of FHSs position statement. I am stunned that anyone in a medical field might seriously state that such procedures cannot be executed while we wait for something like particle sizes to be standardized! (Incidentally, the PVA particles measure 500 - 700 microns.) Medicine, science, thought, technology - all develop by progressive improvement and refinement. If medicine had always been governed by limits as restrictive as those stated, we would never have used GoreTex to govern tissue replacement, never discovered and used penicillin, never realized that bacteria are involved in infection, never quit believing that someones curse must have made us sick. The ignorant self-righteousness of this statement would strike me as funny (one imagines John Cleese haughtily declaiming I cannot stanch your wound until the bandage size is standardized) if it werent the cause of six months of pain and discomfort for me, not to mention distraction from my work and family.
My response:FHS neglects to define durability here. Myomectomy has a 20-30% fibroid recurrence rate in 3 years, yet Intergroup (FHS) covers this procedure. In comparison, UAE to date has shown no regrowth of existing fibroids or growth of new fibroids. According to the SCVIR Website:
My response:And here is the key. Although it has been clearly demonstrated that UAE is a safe and effective treatment for fibroids, is more durable than myomectomy and has both lower complication risk and faster recovery than any of the surgical procedures available, Intergroup - or rather, FHS - is concerned that I might subsequently need a hysterectomy. Indeed, it appears that theres a 5 - 10% chance that, post-UAE, I might need further medical intervention of some kind. Two or three patients out of 500 treated by Dr. Worthington-Kirsch of Philadelphia have needed a hysteroscopic resection of a submucosal fibroid that could not be expelled. To the best of my knowledge, none of the 500 have needed a hysterectomy. In other practices, a few patients have had subsequent hysterectomies.