Nearly 10% of women suffering from cervical cancers and advised hysterectomies are undergoing sub-optimal surgeries. Experts warn that simple hysterectomies (removing the uterus) not only affect disease control in the long run but also cut the overall life expectancy of these patients. They cite two main reasons: one, cervical cancers require radical surgeries that involve removing the uterus along with the surrounding tissue, ligaments that connect the pelvic bone, a part of the vagina and the lymph nodes. Two, patients who have large tumours are not the right candidates for surgery.
“Many doctors are not diagnosing cervical tumours as cancers. They treat them as benign growths,” says Dr. Amita Maheshwari, gynaecological oncologist with India’s largest cancer hospital, the Tata Memorial Hospital (TMH), Mumbai. “Due to the mis-diagnosis, they suggest a uterus removal surgery. While uterus removal may be the right approach for benign tumours, it is not adequate from the cancer point of view,” she adds, explaining that cervical cancers need radical surgery as the disease may have spread in the areas around the tumour. “In any kind of cancer surgery, the tumour is removed along with the margins. One has to have an adequate margin as there are chances of a microscopic or lymphatic spread of the disease which cannot be seen.” She says that when doctors carry out suboptimal surgeries, they leave this margin in the body, and thus the diseased cells too. The margin that cancer surgeons remove in cervical cancers consists of the tissue, ligament, 2-3 cm of the upper regions of the vagina and lymph nodes. Second, in larger cervical cancer tumours that are more than 4 cm, experts rule out the need for surgery altogether as a combination of radiotherapy and chemotherapy has shown an improved survival rate. When patients have their uterus removed and then turn up for cancer treatment, it is less effective.
“For such patients, we have to offer radiation and chemotherapy. Besides the external radiation, we also offer internal radiation which is known as brachytherapy. It is most effective in cervical cancers. However, in the absence of a uterus, we have no place to put our highly-active radiation source,” says Dr. Supriya Chopra, professor of radiation oncology at TMH, adding that in such cases, patients require advanced brachytherapy. In India, there are only about 20 centres that offer this.
Annually, the TMH gets nearly 1,300 cervical cancer patients of whom 10% have been treated suboptimally. Experts say that these patients first land up at a gynaecologist. It is most likely that some gynaecologists are not trained in cancer surgeries and therefore do not carry out a detailed pelvic examination. Cancer experts say that a trained hand may be able to suspect a cancer growth during a clinical examination. “But the best thing is to opt for a pap smear test and if something is seen in it, a biopsy should be advised to prevent inadvertent surgeries,” says Dr. Maheshwari.
A pap smear is a screening procedure for cervical cancer that detects precancerous or cancer cells on the cervix, which is the uterus opening. Cervical cancer affects more than 1.3 lakh women every year and a majority of them seek medical help at an advanced stage. Nearly 67,000 women die due to the disease annually.
Seeking expert advice
Dr. Suchitra Pandit, a former president of the Federation of Obstetric and Gynaecological Societies of India (FOGSI), says that gynaecologists should always seek expert help from the oncology department when they are presented with such cases. “Some gynaecologists may be trained in carrying out cancer surgeries but those who don’t have the expertise should not attempt it without being sure of the diagnosis,” she says.
Experts say that a lack of awareness and training about cervical cancers is the primary reason for suboptimal surgeries. To a certain extent, the profiteering attitude among some doctors can also be blamed for hysterectomies. A 2008 study in the European Journal of Gynaecological Oncology , titled “Tragic results of suboptimal gynaecologic cancer operations”, laid emphasis on postgraduate fellowship programmes to extend the surgical experience and expertise of general gynaecologists in developing and undeveloped countries. “If a gynaecologist does not have enough experience or expertise about gynaecological cancer operations, he or she must consider the possible harm that any surgical intervention might do, and should refer patients to a gynaecological oncology centre without performing any surgery,” the study said.
jyoti.s@thehindu.co.in
