Advertisement

Discussing sarcoma risks during informed consent for nonhysterectomy management of fibroids: an unmet need

Published:September 23, 2017DOI:https://doi.org/10.1016/j.ajog.2017.09.014
      There is no reliable way to distinguish symptomatic uterine fibroids from sarcoma without a surgical specimen. Many women with a uterine sarcoma are initially managed without hysterectomy under a presumed fibroid diagnosis, without understanding sarcoma risks. Currently many alternatives to hysterectomy, including medical and procedural interventions, for treatment of fibroids are promoted. The sarcoma incidence among women with presumed fibroids is 0.29% (1/340) to 0.05% (1/2000). Nonmetastatic leiomyosarcoma has a 63% 5-year survival rate whereas metastatic leiomyosarcoma has a 14% 5-year survival rate. In uterine sarcoma, we often cannot identify who has sarcoma before making a potentially cure-denying decision by delaying surgery. Therefore, women electing an alternative to hysterectomy for fibroids should undergo an informed consent process that specifically includes discussion of uterine sarcoma incidence and mortality. Alternatives to hysterectomy for presumed fibroids remain preferable treatment options for many women with symptomatic fibroids, so long as underlying sarcoma risks are adequately discussed. The challenge for obstetrician- gynecologists then is how to provide better informed consent and maintain the primacy of patient autonomy over our concern to “First, do no harm.” Major threats to patient’s autonomy are faced in the sarcoma risk discussion. How we should present sarcoma risk information to avoid being dismissive of sarcoma or frightening women toward hysterectomy is unstudied. Research is needed to determine how to provide sarcoma risk information with less bias during informed consent.

      Key words

      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'

      Subscribe:

      Subscribe to American Journal of Obstetrics & Gynecology
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect

      References

        • Gaetke-Udager K.
        • Mclean K.
        • Sciallis A.P.
        • et al.
        Diagnostic accuracy of ultrasound, contrast-enhanced CT, and conventional MRI for differentiating leiomyoma from leiomyosarcoma.
        Acad Radiol. 2016; 23: 1290-1297
        • Rosenbaum L.
        N-of-1 policymaking–tragedy, trade-offs, and the demise of morcellation.
        N Engl J Med. 2016; 374: 986-990
        • Donnez J.
        • Dolmans M.M.
        Uterine fibroid management: from the present to the future.
        Hum Reprod Update. 2016; 22: 665-686
        • Gambone J.C.
        • Reiter R.C.
        Hysterectomy: improving the patient’s decision making process.
        Clin Obstet Gynecol. 1997; 40: 868-877
        • Wright J.D.
        • Herzog T.J.
        • Tsui J.
        • et al.
        Nationwide trends in the performance of inpatient hysterectomy in the United States.
        Obstet Gynecol. 2013; 122: 233-241
        • American College of Obstetricians and Gynecologists
        Alternatives to hysterectomy in the management of leiomyomas. ACOG Practice bulletin.
        Obstet Gynecol. 2008; 112: 387-400
        • Seagle B.L.
        • Sobecki-Rausch J.
        • Strohl A.E.
        • Shilpi A.
        • Grace A.
        • Shahabi S.
        Prognosis and treatment of uterine leiomyosarcoma: a National Cancer Database study.
        Gynecol Oncol. 2017; 145: 61-70
        • Wright J.D.
        • Ananth C.V.
        • Lewin S.N.
        • et al.
        Robotically assisted vs laparoscopic hysterectomy among women with benign gynecologic disease.
        JAMA. 2013; 309: 689-698
        • American Cancer Society
        Cancer facts and figures 2017.
        American Cancer Society, Atlanta (GA)2017 (Available at:) (Accessed July 30, 2017)
        • Gallicchio L.
        • Harvey L.A.
        • Kjerulff K.H.
        Fear of cancer among women undergoing hysterectomy for benign conditions.
        Psychosom Med. 2005; 67: 420-424
        • Touqmatchi D.
        • Boret T.
        • Nicopoullous J.
        The quality of operative consenting against RCOG advice as standard.
        J Obstet Gynecol. 2010; 30: 159-165
        • Entwistle V.
        • Williams B.
        • Skea Z.
        • Maclennan G.
        • Bhattacharya S.
        Which surgical decisions should patients participate in and how? Reflections on women’s recollections of discussions about variants of hysterectomy.
        Soc Sci Med. 2006; 62: 499-509
        • Hoffman M.
        • Lindh-Astrand L.
        • Ahlner J.
        • Hammar M.
        • Kjellgen K.I.
        Hormone replacement therapy in the menopause: structure and content of risk talk.
        Maturitas. 2005; 50: 8-18
        • Cheng K.Y.
        What does respect for the patient’s autonomy require?.
        Bioethics. 2013; 27: 493-499
        • Gurm H.S.
        • Litaker D.G.
        Framing procedural risks to patients: is 99% safe the same as a risk of 1 in 100?.
        Acad Med. 2000; 75: 840-842
        • Schwartz P.H.
        • Meslin E.M.
        The ethics of information: absolute risk reduction and patient understanding of screening.
        J Gen Intern Med. 2008; 23: 867-870
        • Gong J.J.
        • Zhang Y.
        • Feng J.
        • et al.
        How to best obtain consent to thrombolysis: individualized decision making.
        Neurology. 2016; 86: 1045-1052
        • Mazur D.J.
        • Hickman D.H.
        Treatment preferences of patients and physicians: influences of summary data when framing effects are controlled.
        Med Decis Making. 1990; 10: 2-5