November 30, 2009

Radiology Today Interview With John C. Lipman, MD, FSIR — The State of UFE Acceptance Today

Radiology Today
Vol. 10 No. 19 P. 28

John C. Lipman, MD, FSIR, is medical director of the Atlanta Interventional Institute. As an internationally recognized fibroid expert, his area of expertise includes the minimally invasive uterine fibroid embolization (UFE) procedure. He recently discussed the current state of acceptance of this less invasive treatment for uterine fibroids with Radiology Today.

Radiology Today (RT): What is the current state of UFE acceptance among patients?

Lipman: There is a very high acceptance of UFE with patients. The procedure is one of the biggest medical breakthroughs for women. Women who have undergone the procedure are very happy with their results. Over 90% of patients see dramatic improvement in their symptoms or their symptoms are gone after undergoing UFE. In my hands, the procedure is done on an outpatient basis, and the patient returns home with nothing but a Band-Aid. The recovery period is between four and five days, so women are out of work typically for only about a week. Compared to surgery, UFE is much safer, has much lower risk, and much quicker recovery time.

RT: How have clinicians accepted UFE?

Lipman: Some gynecologists have accepted the procedure. But there are still many that, for whatever reason, do not accept it, despite the fact that there has been significant published data in their literature, as well as the general medical literature, showing how safe and effective UFE is for women.

For example, in the August 2008 American College of Obstetricians and Gynecologists [ACOG] Practice Bulletin, there was an article titled “Alternatives to Hysterectomy in the Management of Leiomyomas,” which clearly states that UFE is safe and effective for women who want to keep their uterus. More recently, The New England Journal of Medicine issued a review of a patient who underwent UFE. The Journal of the American Medical Association has also addressed the topic earlier this year.

There shouldn’t be any reason why a gynecologist who is treating a woman who is suffering with fibroids and has significant symptoms from those fibroids shouldn’t mention UFE as an option. Surprisingly, however, in 2009, many women are still not told about this procedure by their gynecologists. We have a lot of work to do. While most of the women I see in my practice come from gynecology referrals, there are still a lot of women not hearing about this option.

RT: Are gynecologists opening up more to the option of UFE for women with uterine fibroids?

Lipman: There is surprisingly little generalized acceptance of UFE among the gynecology community. I do receive positive feedback from gynecologists who say they are happy with the results of the procedure but, in many instances, if it were entirely up to them, they would do the hysterectomy instead. With the available data on the success of UFE, you would think there would be increased acceptance. However, I haven’t noticed a lot of change. I recently spoke before the Georgia chapter of the ACOG about UFE and told its members in attendance that, in my opinion, every woman you see who is suffering with uterine fibroids needs to hear about embolization as an option. But that’s just not happening.

Some of the reason why gynecologists are not mentioning UFE has to do with the interventional radiologists. The biggest complaint I have heard from gynecologists across the country—and it’s a legitimate one—is that there is a subset of interventional radiologists that are not taking care of these patients after performing the UFE. They perform the procedure but leave the clinical aftercare to the gynecologist. I agree with the gynecologists that this practice is not acceptable. If you’re doing UFE, you need to take care of these patients. You cannot abdicate the clinical responsibility for the care of these patients to someone else. Based on a Society of Interventional Radiology [SIR] survey conducted in 2006, one third of interventional radiologists were not handling the clinical aftercare.

Each group needs to step up. While the Internet is a great tool to use, a woman shouldn’t have to find out about her options for uterine fibroids on the Internet. That’s the physicians’ responsibility. Many gynecologists are telling women only about the options that they can provide. The interventional radiologists need to step up and take care of the clinical responsibilities. There has been increasing emphasis on this aspect of IR [interventional radiology], as evidenced during recent SIR meetings.

RT: Are gynecologists adopting the procedure themselves, which so often happens with IR procedures?

Lipman: There are a few gynecologists who are trying to perform UFEs. If they do a good job, that’s fine. But there are a lot of people, including diagnostic radiologists, vascular surgeons, interventional cardiologists, and some part-time interventional radiologists, who are dabbling in UFEs who shouldn’t be. IR cannot claim any procedure (UFE or otherwise) just because it is done under imaging. We need to demonstrate our clinical and technical abilities as the leaders in image-guided, minimally invasive, targeted treatments.

RT: How can interventional radiologists work to increase the acceptance of UFE?

Lipman: Interventional radiologists can talk to hospital administrators and marketing people to tell their stories; it’s a story worth telling. You have patients who are suffering with severe uterine fibroid symptoms such as heavy menstrual bleeding and pelvic pain. There are more than 1 million women currently in the United States who we call the “silent sufferers.” They know that fibroids aren’t going to kill them, but having fibroids is making their lives miserable. They don’t want a hysterectomy, but they don’t know of any other options. With this many women suffering, it is our job to educate the public about UFE, which has the potential to give these women their lives back.

RT: How has UFE changed the role of interventional radiologists where they practice?

Lipman: In the hospitals years ago, no one knew us. Today, that’s not the case. In addition to treating fibroids, there are a number of procedures we perform that replace the need for surgery. The patients are happy, the risk is less, and the hospitalization time is significantly less or nonexistent in the case of outpatient procedures. Hospital administrators like this. They like patients who are happy about the care they receive. We are definitely now on their radar, particularly in this cost-containment environment.

More things today are being measured on an outcomes-based scale. When it comes to reducing costs, IR can play a role. Doing things less invasively and safer hopefully costs less—certainly much less when you consider the patient’s time away from work with some of these models. With UFE, the patient may be out of work for one week vs. eight weeks with surgery. The cost savings is tremendous, the patients are very happy and, therefore, the hospital administrators are happy.

RT: How are women being educated about their options?

Lipman: Currently, unfortunately, many women are not hearing about UFE from their gynecologists, which is where they really should be hearing about it. We’ve discussed that women often search the Internet for information on uterine fibroids, and that’s how they might learn about UFE. However, they are also hearing about the procedure through word of mouth and by talking directly to other women who have had the procedure. Women play a role in that they need to increase the dialogue. While fibroids are common in child-bearing–age women of all races, they are particularly common among African American women. Women need to talk to other women in their families to let them know about the symptoms they have been experiencing and what, if any, treatments they have undergone to alleviate those symptoms. The symptoms, such as the heavy bleeding and urinary frequency, can be embarrassing. They need to get beyond that and have the discussion. While the topic may be embarrassing, undergoing an unnecessary hysterectomy is tragic.

As an example, Beverly Johnson, the first African American model to appear on the cover of Vogue magazine, tells the story of how she suffered with uterine fibroids discovered while she was in her early 30s. Her symptoms worsened in her 40s. At the time, the only option presented by her gynecologist was to undergo a hysterectomy. She asked about other options and eventually her gynecologist discussed myomectomy, a procedure which involves surgically removing the fibroids. This is still a form of surgery that requires a six- to eight-week recovery period. However, she did opt for this procedure in order to keep her uterus intact.

Because of the large number of fibroids in her uterus, not all of them could be removed, and her symptoms returned in just a few months. The recurrence of symptoms with myomectomy is common. Reluctantly, she eventually agreed to undergo a hysterectomy. Unfortunately, like a number of women who have had a hysterectomy, she has had complications afterward. Also, her gynecologist never mentioned UFE to her on either occasion. We shouldn’t be unnecessarily removing the uterus for benign disease. That’s why speaking to other women about their options is important. Beverly and I speak publicly about her experiences with uterine fibroids. To her credit, she has taken lemons and made lemonade. She can’t speak specifically to UFE, but she can educate women that they clearly have excellent less invasive options.

RT: What is the role of interventional radiologists in educating women about UFE?

Lipman: Women can connect with interventional radiologists by reaching out to them on their own. The responsibility of IR is to take advantage of the opportunity to educate women about the less invasive options for fibroids. If they aren’t discussing UFE and accepting the clinical responsibility involved, then they shouldn’t be doing the procedure.

RT: What is the role of gynecologists in educating women about UFE?

Lipman: They are an important part of this process. Most women who suffer with fibroids first contact their gynecologists. The gynecologists have to tell women about all the options, not just the ones they can provide.

RT: What should women do when faced with making a decision regarding how best to treat their uterine fibroids?

Lipman: If women are interested in these nonsurgical options, they need to see an interventional radiologist who specializes in UFE. That’s important. In some instances, a gynecologist may not have the specifics on who qualifies for UFE. I have heard of instances where women are told their fibroids are too large for them to undergo UFE or that they have too many fibroids for the procedure. This is misinformation. You can’t have too many fibroids to have UFE. While it’s important to see a gynecologist to discuss all the options, you need to see an interventional radiologist who is an expert in this area to receive the specifics of the procedure. Not all interventional radiologists have expertise in UFE, however.

RT: How significant is UFE becoming in terms of volume?

Lipman: I’ve seen steady, large volume increases in UFE. Clearly, the message is resonating with women. Every year that the procedure has been performed, it has increased in volume. We’re well into the six figures when it comes to how many women in the United States have undergone UFE. However, with 1 million women on the sidelines, there are many more who could still benefit from the procedure.

RT: Is its value being perceived by noninterventionalists within a radiology group?

Lipman: In my instance, that was one of the reasons I went into private practice five years ago. For the first 14 years of my career, I was with a large radiology group that had subspecialties. However, the biggest impediment was the noninterventional people in my practice. Going into solo practice has allowed me to take care of patients. I have a full-time office practice, unencumbered by noninterventional people who had no understanding of the importance of a clinical practice. They never had a clinical practice before I came to the group. I insisted on having an office and a clinical practice. Having that office, staffing it, and with all the overhead that comes with it, was something the noninterventionalists didn’t understand. That became an issue over time. I wanted to take care of patients. They wanted me to read films and valued film reading over clinic time. It is a challenge for a number of groups.

But talking to other people during the past five years, that situation seems to be getting better for interventional radiologists. There’s not as much push-back from noninterventionalists. The ACR and SIR are working more closely together, realizing the importance of what IR brings to a radiology group. Interventional radiologists appear to be getting more support than they used to.