Morcellation: Medical foreknowledge and cancer metastasis

Morcellation: Medical foreknowledge and cancer metastasis

Cancer: The Risk of Biopsy and Surgery

It has been known by surgeons since the 1930s that solid cancer masses should not be cut because cancer cells can escape the body’s barriers and metastasize. [1] The relation of surgery to metastasis was made more definite in a research article published in 1979. [2] Similarly, needle biopsies puncture tumor masses, allowing cancer cells to escape, implant and multiply, that is, metastasize. [3]

Radiographic images of needle-track metastases are horrifying to see because eerie, linear patterns of cancer haveNeedle Tract Metastases been created by a diagnostic motivation that neglects patient safety. (Medical error is often imbedded in perfectly executed routine procedures. The narrow motivation to act is very strong in medicine, whether the acts are diagnostic or for treatment.)

Even the physiological stress of surgery can cause metastasis. When freed by some disturbance, cancer cells travel nourished by the blood or lymph. Unless demolished by turbulence in fast-rushing blood or killed by immune cells in blood or lymph, they circulate until they link to the wall of a vessel, pass through, implant in tissue, then they multiply. The cancer has been “upstaged” (raised to the metastatic stage) by foreseeable acts of routine medicine.

About 600,000 hysterectomies are done in the U.S. per year, estimates range from 17% to about one third of them are done as treatment for the growth of benign fibroid tumors of the uterus. The CDC states that fibroid symptoms are the most frequent indication for the surgery. [4] Hysterectomy is one recommended treatment for symptoms of serious, benign uterine fibroid growths.Hysterectomy

The traditional surgery for hysterectomy is to make an incision in the lower abdomen, resect the uterus and remove it whole. Another route is to do the removal through the vagina. These are major surgeries, requiring weeks, perhaps more than a month to recuperate. There are now “minimally invasive” surgeries using a laparoscope.

Laparoscopic surgery requires small incisions only. Into these incisions are inserted tubes with a light, camera and, through separate channels, small surgical instruments. The entire surgery can be done manually or can be robot-assisted. The uterus is too large to pass through the laparoscopic tubes, so it must be cut to small pieces, before it can be removed. The chopping process may be done manually or much more quickly with a powered machine inserted through a tube. The latter process is called power morcellation.

Morcellation

The head of the power morcellator is not dissimilar to the blades of a blender. Other structures, like the bladder orpower-morcellator-diagram blood vessels, may be cut unless perfect skill is used. The power morcellator chops the uterus into removable pieces but in the process of chopping scatters pieces within the abdominal cavity. These pieces then have to be found and removed through the tube by a steel claw; a certain amount of debris is always left. Any method of hysterectomy that requires cutting the uterus into pieces has its own dangers.

Some women are told by their physician about the possibility of cancer lurking in the uterus. They are given the figure that such cancers occur in “one in ten thousand” women. They are typically not told two things. One is about the morcellation process. The other is that among women with symptom-producing fibroid masses, there is a much greater risk of uterine cancer – perhaps one in 350 women. [5] Of these, perhaps 64.3% women may experience metastasis from morcellation. [6]

The body’s immune system will kill most cancer cells soon after they are formed. Leaving the cancer cell or cells in place puts them at greater temporary risk of destruction by immune cells. Morcellation disseminates the cancerous tissue – seeds the cancer cells – to the peritoneal surfaces where they are more likely than not to implant and grow. If you were a candidate for hysterectomy, would this information sell you on the procedure?

There is more a patient should know. Whether the uterus is removed, whole or in pieces, any cancer cannot be identified except from laboratory inspection of the excised uterus or uterine material. Certainly, tiny clusters of cancer cells too small for the eye to see will not be found with a laparoscope, nor will they be seen inside a fibroid.

With a morcellated uterus, the cancer cells may be among the debris left in the abdominal cavity. Cancer cells lack theMorcellation intercellular cohesiveness of normal cells; as a consequence cancer cells have a greater chance of being flung into the debris where they may implant on the vital tissues within the abdomen. (Morcellation, thus bypasses the bloodstream where many free cancer cells can be detected and destroyed by white blood cells.) Morcellation — which combines operative stress, the disturbance of cancer growths, and rapid mechanical dissemination of cancerous tissue — appears to increase the risk of metastasis. At the moment of implantation, uterine cancer has metastasized.

Medical Foreknowledge

The medical profession knows these dangers but continues to do biopsies and surgeries that increase the likelihood of cancer metastasis. The specific risks of metastasis attached to morcellation have been clearly described in articles within gynecological and cancer journals. [7] At least one gynecological oncologist, the author of such an article, continues to refer patients for procedures that most likely will involve morcellation. [8] Indeed, morcellation is the most common means of hysterectomy now used.

The question here is not why the FDA approved a power morcellator as late as 2010, with no clinical evidence. [9] The paramount question is why the professionals themselves, obstetrical surgeons, given what ought to be decades-old common knowledge of increased cancer risk, persist in performing morcellation?FDA

A second question would ask why physicians who prefer morcellation, fail to explain properly the true risks of morcellation to their patients, women whose health ought to be their uppermost concern (primum non nocere)? I suggest that the root answer to these two questions derives primarily from the narrowness of perspective created by the inductive process of clinical judgment.

To the obstetrical surgeon, the laparoscopic procedure is less invasive, safer (in the short term), less painful, quicker to perform, decreases hospital stay, reduces recovery time, and minimizes scarring. This clinical reasoning is focused on the problem at hand, and does not include merely potential future events, nor would it necessarily consider the abstract risk of a metastasized cancer, an outcome only the gynecological oncologist will see. A surgeon’s business in these cases is to remove a troublesome uterus. To repeat: Medical error is often imbedded in perfectly executed routine procedures.

We know from watching its behaviors over centuries that the medical profession becomes invested in its established practices and is resistant to change — unless forced by circumstances. We know the profession’s clinical thinking is action-oriented, not outcome-oriented. We see this in the large numbers of medical errors and in blindness to long-term outcomes, including vaccine damage. It is quite resistant to statistical information that conflicts with established beliefs and practices, and it disparages (or attacks) critics, especially insiders.

Drs. Amy Reed and Hooman Noorchasmamy-reed and husband

Drew Hofmann [10] tells the story of morcellation and the personal experience of two eminent physicians. [10] They are married. She, Dr. Amy Reed (MD, PhD), is an anesthesiologist at Beth Israel Hospital in Boston. He, Dr. Hooman Noorchasm (MD, PhD) is a cardiothoracic surgeon at Brigham and Women’s Hospital; he also lectures on surgery at Harvard Medical School. She underwent what was to be a routine morcellation procedure for the removal of fibroids by hysterectomy. The same procedure is used on hundreds of thousands of women each year. An examination of the removed tissue revealed a rare form of uterine cancer, the bits of which had been scattered throughout her abdominal cavity by the morcellation procedure. As a result of the unintended surgical dissemination of uterine cancer tissue, she now had stage IV uterine cancer. We will never know, if without morcellation, the body would have destroyed the cancer, or if the entire uterus had been removed in surgery there may never have been a diagnosis of terminal cancer.

The husband, himself a surgeon, has researched the morcellation procedure and its established place among HT_amy_reed_hooman_noorchashm_sk_140417_16x9_992gynecologists. In the interest of patient safety, he has written letters to professional associations, manufacturers, the FDA and many others in a relentless effort to expose the dangers of morcellation and to ask questions regarding morcellation. He has also written articles for public consumption to educate potential patients. (Articles have also been written by other authors in the Boston Globe and the Wall Street Journal.) His goal is to persuade “…the medical community to halt the use of intracorporeal uterine morcellation”. [11] Dr. Noorchasm says,

“This medical specialty’s leaders and the companies involved have known about the hazard and have blindly accepted the collateral damage to their patients for years.” [12]

(His quotation could apply to vaccination, as well. Blindness to “collateral damage” seems to be intrinsic to medical thinking.)

Dr. Norchasm is now seen as the worst sort of traitor: an insider questioning both the level of concern for patient safety and threatening an established, frequently used surgical procedure. He has been chastised, isolated, insulted, and met with denial. It has been suggested that “…he is acting irrationally due to grief over his wife’s condition” (patronized) and that “…it would be much wiser for him to remain quiet to protect his career” (threatened). He has seen, “…colleagues, hospitals and other institutions quickly close ranks, isolating the whistleblower and protecting their own financial interests.” Many gynecologists have jumped to defend the procedure and to deny the clear danger posed by morcellation. [13]

An organization formerly known as the American Association of Gynecologic Laparoscopists, now the AAGL, has AAGLdiscouraged performing morcellation on older women because of its risk in spreading cancer within the body. (Dr. Reed, above, was 40 years old; the average age-range for hysterectomies is 40-44.) They admit the tool “…may spread and worsen hidden cancers” and that all “patients should be advised of the risk.” In a letter sent to doctors, the AAGL said that morcellators can be a “safe option,” but “All existing methods of tissue extraction have benefits and risks, which must be balanced.”. [14] What benefits balance a risk of death by cancer? What professional ethics make such a risk to a patient acceptable?

Dr. Noorchasm, however, with his persistence, the credentials of his status, and against the backdrop of his wife’s tragedy, has made morcellation, if not yet “too dangerous,” at least open to question. The procedure is under further review by the influential American College of Obstetricians and Gynecologists.

Johnson & Johnson is the largest manufacturer of power morcellators. The company has suspended worldwide sales pending word from the FDA and the medical community. [15] Also, the FDA issued a notice on April 17, 2014 that discouraged the use of power morcellation, saying about the use of the device, “…an analysis of currently available data [shows that power morcellation]…poses a risk of spreading unsuspected cancerous tissue, notably uterine sarcomas, beyond the uterus.” [16] This FDA notice is apparent progress. The decision is ultimately in the hands of the FDA.

Clinical Tunnel Vision

As a general rule, as we have seen many times, medicine stays the course unless acted upon by a considerable outside force. The power morcellation procedure could be declared “too dangerous” and discontinued or severely limited. It is certain that if left to themselves, gynecologists would not have raised the question of patient safety and would, unconcerned, continue power morcellation.

Clinical logic produces a kind of tunnel vision. The logic of clinical induction leads from evidence, through a set of biases, to conclusions – a conclusion of diagnosis and a conclusion as to treatment. The focus of clinical thinking is the immediate circumstance; it is bound up in itself. [17] Medical certainty in and of itself is a species of truth.

When your culture has spent over 2000 years making truths from the humoral theory of diseases, lived by those truths, and made a living from the exercise of such truths, a scientific facticity from outside the profession is only one more opinion of no particular weight. In medicine, important truths do not exist as clear-cut entities separate from opinion, action, power and authority.

Works Cited

1. D. Davis, The Secret History of the War on Cancer, Basis Books, 2007.
2. E. H. Krokowski, Is the Current Treatment of Cancer Self-Limiting in the Extent of its Success?, Journal of the International Academy of Preventive Medicine, 6(1), 1979, pp. 23-39.
3. M.S. Metcalfe, et al. Useless and dangerous – fine needle aspiration of hepatic colorectal metastases. British Medical Journal, 328, 28 February 2004, pp. 507-508. See reference section, especially items 3 through 7. Significant quote from page 507: “Repeated ultrasonography and computed tomography did not find recurrence of the disease, either in the liver or elsewhere. Therefore it seems likely that the patient would have remained free of the disease after his hepatectomy but for the FNAC [Fine Needle Aspiration Cytology] biopsy performed early in the management of his disease. The patient subsequently died.”
4. See: http://www.cdc.gov/mmwr/PDF/ss/ss4604.pdf, accessed 6/11/2014. An indication for surgery means neither that the surgery is the only option nor that the surgery is necessary. Surgery is what surgeons do. Gynecological surgeons do surgery for a living; of course they recommend it when possible. That is why actuarial studies consistently find where there are more surgeons in a population there are higher rates of surgery, unrelated to underlying necessity.
5. T. Hampton, op. cit.
6. See: M. A. Seidman, et al., “Perioneal dissemination complicating morcellation of uterine mesenchymal neoplasms”, PLoS One. 2012; 7[11]]:e50058; see: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC3506532/, accessed 6/11/2014.
7. A. Takeda, et al., “Parasitic peritoneal leiomyomatosis [benign neoplasm] diagnosed 6 years after laparoscopic myomectomy with electric tissue morcellation: Report of a case and review of the literature”, Journal of Minimally Invasive Gynecology, 14(6), 2007, pp. 770-775; Z. Ordulu, et al., “Disseminated leiomyomatosis after laparoscopic supracervical hysterectomy with characteristic molecular cytogenic findings of leiomyoma”, Genes, chromosomes and cancer”, 49(12), 2010, pp. 1152-1160; C. Della Badia and H. Carini, “Endometrial stromal sarcoma diagnosed after uterine morcellation in laparoscopic supracervical hysterectomy”, Journal of Minimally Invasive Gynecology, 17(6), 2010, pp. 791-793; M. P. Milad and E. A. Milad, “Laparoscopic morcellator-related complication”, Journal of Minimally Invasive Gynecology, 9 December 2013.
8. D. Hofmann, “When a common gynecological procedure turns deadly”, Life Extension, 20(7), July 2014, pp. 75-83.
9. D. Hofmann, op. cit., p. 79.
10. D. Hofmann, op. cit.
11. T. Hampton, “Critics of fibroid removal procedure question risks it may pose for women with undetected uterine cancer”, Journal of the American Medical Association, published online 6 February 2004, http://jama.jamanetwork.com/, accessed 6/10/2014.
12. D. Hofmann, op. cit., p. 80.
13. See: http://online.wsj.com/news/articles/SB10001424052702304428004579351130202006704, accessed 6/10/2014.
14. See: http://online.wsj.com/news/articles/SB10001424052702304655304579550343278621338?mod=WSJ_LatestHeadlines&mg=reno64-wsj. Accessed 6/10/2014.
15. See: WSJ, cited above.
16. See: http://www.fda.gov/NewsEvents?Newsroom?PressAnnouncements/ucm393689.htm and http://www.goldbergattorneys.com/morcellation-cancer-fibroid/, accessed 6/10/2014.
17. Cf., M. Foucault, op. cit., pp. 108-109. Foucault is creating the “clinical gaze” as an ideal type. He therefore specifically excludes the effects of predisposition or bias. He claims that experience is the effect and observation is the cause of that effect. However, the clinical gaze is impossible without the shaping effects of prior experience. Without experience, there is clinical blindness. Experience is a necessary precursor to the clinical gaze, without it there is the blindness of the person.