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RANZCR: Uterine Fibroid Embolisation: the Past, the Present, and the Future
from Inside News September 2020
by RANZCR
The Royal Australian and New Zealand College of Radiologists (RANZCR) Inside News September 2020
The past
Uterine fibroids are estimated to be present in up to 75 per cent of women, and cause symptoms in up to 35 per cent. Patients with small fibroids or with mild symptoms may be suitable for conservative treatment options. For women with large fibroids or who have failed conservative treatment, a more definitive approach is needed [1] .
Fibroid embolisation (UFE) was first described in 1974 by interventional radiologist Jean-Jacques Merland. It became a mainstream treatment option following a landmark paper in The Lancet in 1995, followed on by the REST and EMMY trials in the early 2000s [1] . High-level evidence now shows us that fibroid embolisation performed by interventional radiologists (IRs), provides women with similar improvement in quality of life at up to 10 years after embolisation compared with traditional surgical treatments, including hysterectomy and myomectomy [1] .
In 2006, the Medical Services Advisory Committee (MSAC) compared the efficacy, cost, and safety of UFE. They recommend public funding of embolisation (MBS item 35410), however placed a condition that referrals should come from a gynaecologist in order for Medicare to provide the rebate [2] .
The present
While the provision of a Medicare item number seemed like a milestone in Australia, the reality has been a stark contrast. Recent data from five consecutive years in Australia shows that there has been an average of only 145 Medicare-rebated UFEs per year, compared to an estimated over 6,000 fibroid-related surgeries and over 30,000 uterine surgeries in total! [1] (see figure 1). A similar disparity is also being presented in overseas data.
Figure 1: Comparing the number of UFE procedures with the number of surgeries for fibroid disease in Australia. Source: Department of Human Services website www.medicarestatistics.humanservices.gov.au/statistics/ mbs_item.jsp
A study from France showed there are approximately 2,000 UFEs being performed each year compared with 40,000 uterine surgeries [3] . In Spain, a study showed that less than 150 UFEs were being performed each year compared with 50,000 hysterectomies [3] .
These numbers are likely representative of a worldwide trend, including in New Zealand. It is important to also consider these numbers in the context with recommendations from the Royal Australian and New Zealand College of Gynaecologists. They recommend that gynaecologists should counsel the patient about all treatment options before offering surgery, including UFE. The worldwide numbers presented don't support the notion that women are being offered a balanced view on the safety and efficacy of UFE.
The cause of this disparity between UFE and surgery is multifactorial [1,3] . Many IRs will argue that scepticism from gynaecologists remains a primary reason for the lack of referrals. The inability of GPs to provide a direct referral pathway due to restrictions on the Medicare item number is also likely to be a contributor.
There is also a general lack of awareness about UFE amongst GPs and the public. Finally, for IRs to provide a service they must be recognised as clinicians and this means working in the patient's healthcare team but also taking 'ownership' of the primary care of the patient for that procedure. This will include clinical duties of a specialist doctor expected by the general public, such as consultation, admission, procedure, post-procedure care, and follow-up.
Treating patients in this manner is different to the traditional role of radiologists who generally provide a technical adjunct while handing holistic care back to the referring clinical team.
The future
We still have some work ahead if Australian and New Zealand women are to have access to this low-cost uterinesparing treatment. Our College, via the Interventional Radiology Committee, has developed a position statement outlining aspects of evidence on the safety, efficacy, and cost of UFE. This included the vital role of IRs in fibroid management and supports the MBS review recommendations to remove the restriction of gynaecologist referral [4] which is in the current Medicare item 35410 [5] . This will allow more open access for women via direct referral from their GP, and allow IRs, GPs and gynaecologists to work in a multidisciplinary team.
Now is the time that we make the clinical radiology specialty of interventional radiology exist in Australia and New Zealand. For IRs to own a procedure, we must be recognised as frontline physicians and not secondary caregivers like we have been in the past. If this does not happen, ownership of procedures that IR designed and developed will be taken over by other specialties, just like what happened with coronary angiography and what is happening currently with peripheral angiography.
All College Fellows can play a role in this process including diagnostic radiologists who do not perform advanced procedures—we need support from all radiologists to have the mandate to make this reform to allow IRs to practise in the manner that we need.
Only once IR exists as a specialty, can we truly take ownership of the procedure and establish better referral and treatment pathways. This will work in tandem with education for GPs and the general public around what IR is, and what we can do for women with fibroids. Excellent College resources such as the Inside Radiology website (www.insideradiology.com.au) are available as a resource for patients who are considering their treatment options.
Social media is also a modern platform that we must harness. There may also be a role to work with industry in this regard where we can mutually advocate for our craft. By the end of this year, an Australian website will go live, providing support for advocacy of UFE in Australia (www.ask4UFE.au).
Don't look behind, look ahead, as there is an optimistic future for UFE in Australia and New Zealand. I foresee that within the next five years we can show College Fellows that our collective work has provided many thousands of women with uterine-saving treatment and at the same time grown the specialty of IR.
Dr Warren Clements Interventional Radiologist Alfred Heath and Monash University Interventional Radiology Committee, RANZCR
Twitter: @Warren_IR
References
1. Clements W, Ang WC, Law M et al. Treatment of symptomatic fibroid disease using uterine fibroid embolisation: An Australian perspective. ANZJOG. June 2020. 60(3) pp 324-329. www.doi.org/10.1111/ ajo.13120
2. Medical Services Advisory Committee. Uterine artery embolisation for the treatment of symptomatic uterine fibroids, Assessment Report, January 2006. [Accessed November 2018.] Available from URL: www.msac.gov.au/
3. Makris GC, Butt S, Sabharwal T. Unnecessary hysterectomies and our role as interventional radiology community. CVIR Endovasc. 2020 Dec; 3: 46. doi: 10.1186/s42155-020-00138-x
4. Australian Government Department of Health, Medicare Benefits Schedule Review Taskforce. Report from the Vascular Clinical Committee. 2018. [Accessed 5 August 2020]. Available from: www1.health.gov.au/internet/main/publishing. nsf/Content/mbs-review-2018-taskforce-reportscp/$File/VCC-Final-Report-Consultation-Report.pdf
5. Australian Government Department of Health, Medicare Benefits Schedule Online. [Accessed 5 August 2020]. Available from: www9.health.gov.au/ mbs/fullDisplay.cfm?type=item&q=35410
If this is how other women live, I have not been living!:
How uterine fibroid emobolisation changed a young woman’s life
Stephanie got used to managing difficult periods, so much so that it became the norm. “I was used to heavy bleeding and a lot of cramping during my periods,” said Stephanie. “I was diagnosed with endometriosis when I was 20 and eventually had surgery for the condition 10 years later.”
It was during the surgery that the gynecologist identified several uterine fibroids that were about 5 cm big. Over the course of the next two years, they grew to about 12 cm.
“As the fibroids got bigger my symptoms intensified. Bleeding during my periods got even heavier and I could hardly stay awake during my cycle. I was completely exhausted.”
The symptoms quickly altered the way Stephanie was able to live her life. “I was in constant pain. My stomach was so bloated that I looked like I was six months pregnant and even sitting down or tying up my shoes was excruciating. I could only wear loose-fitting clothing as I couldn’t stand any pressure on my stomach and I wanted to hide how swollen it was.
“It eventually got to the stage where I needed to go to the toilet every 30 minutes. I had to plan my whole day around where and when I could get to a bathroom—which isn’t easy when you have an hour commute just to get to work!
Stephanie’s gynecologist made her aware of treatment options ranging from hormonal medications to major surgery. “I considered getting a hysterectomy for about six months, but as a young woman, I couldn’t believe that was my only option.”
Stephanie sought out more specialists for a second opinion and during her research found an old YouTube video on uterine fibroid embolisation (UFE).
She said,” I found an interventional radiology clinic in Sydney who offered the procedure and I made an appointment as soon as I could. The doctor took me through the procedure, and I knew this was the right option for me. To be honest, it seemed too good to be true, given the improvements that could be gained and avoiding a surgery under general anesthetic.”
After the procedure, Stephanie’s symptoms improved dramatically. “The bleeding during my first few periods was basically non-existent compared to how they had been before. I remember thinking, ‘If this is how other women live, I have not been living!’”
“The relief and improvement in all my other symptoms were drastic—it was beyond worth it. I wanted to share my story so that other women who are suffering like I was can learn more about UFE and consider if it is the right treatment option for them. It gave me back my life and I am extremely grateful to my medical team for that. I couldn’t recommend the team and the procedure enough, I haven’t looked back since.”
