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Volume 21, Issue 6 ( June 2023 2023)
IJRM 2023, 21(6): 521-522 |
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Cecannecchia C, Cioffi F, Cioffi A. Overtreatment by hysterectomy for cervical intraepithelial neoplasia: Medico-legal aspects. IJRM 2023; 21 (6) :521-522
URL: http://ijrm.ir/article-1-2697-en.html
URL: http://ijrm.ir/article-1-2697-en.html
1- Department of Anatomical, Histological, Forensic and Orthopaedic Sciences, Sapienza University of Rome, Italy.
2- Fertilitas Day Surgery Reproductive Medicine, Salerno, Italy.
3- Department of Clinical and Experimental Medicine, Section of Legal Medicine, University of Foggia, Italy. , an.cioffi19@gmail.com
2- Fertilitas Day Surgery Reproductive Medicine, Salerno, Italy.
3- Department of Clinical and Experimental Medicine, Section of Legal Medicine, University of Foggia, Italy. , an.cioffi19@gmail.com
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Dear Editor,
Recent scientific evidence shows that the number of hysterectomies is far greater than those needed. In the last 10 yr in Italy (and not only), the number of hysterectomies performed for cervical intraepithelial neoplasia (CIN) has also increased in a worrying way (1). However, the recommendations of the World Health Organization (2) and the most recent European guidelines (3) make this clear that in the case of CIN 1 of a histological high-grade squamous intraepithelial lesion (i.e., CIN 2-3) not exceeding the basal membrane, and of invasive cervical cancer up to stage T1a1, conservative diagnostic-therapeutic management should be preferred. In the above cases, hysterectomy constitutes an overtreatment as the risk of complications of surgery outweighs any health benefit to the patient. In some circumstances, hysterectomy can be a (partially or totally) resolving tool for CIN: microinvasion, histologically confirmed recurrent high-grade CIN, co-presence of other uterus pathologies that worsen the overall clinical-gynaecological picture, such as prolapse, fibroids, pelvic inflammatory disease and endometriosis (4). Except in these cases, less invasive methods for the treatment of CIN 1 and of histological high-grade squamous intraepithelial lesion are recommended.
The reasons behind the inadequate use of hysterectomy (i.e., in the absence of specific indications) are attributable both to the insufficient scientific updating of some gynaecologists, and to the spread of the phenomenon of defensive medicine, also called defensive medical decision-making (5). The actions of the gynaecologist are no longer guided by scientific evidence but motivated primarily by litigious concerns. The increased incidence of medico-legal litigation in the healthcare sector inevitably instils in the surgeons’ minds the fear that their decisions may be challenged. Namely, gynaecologists end up practicing more than the necessary hysterectomies (even in the absence of specific indications) in fear that using less invasive procedures may be challenging in case of an unlikely progression of the neoplasm.
The increase in unnecessary hysterectomies has significant medical-legal repercussions. First, a hysterectomy is an invasive surgery associated with a risk of mortality of 0.4% and a much higher risk of intra- and post-operative complications (1). Complications and harms of an unnecessary hysterectomy can expose the doctor and/or healthcare facility to a greater risk of legal defeat. In fact, both will be called to justify the use of an avoidable invasive procedure. In addition, a hysterectomy can also cause mental damage in women (6).
The uterus preservation can help to preserve fertility, and that is why, in primis, this issue has been discussed here, but uterus is not an organ exclusively aimed at procreation but is, in all respects, an indispensable part of the sexual identity of the woman, regardless of age. Therefore, it is urgent to implement the quality of the scientific update of gynaecologists; it is also essential to carry out a standardized control of healthcare facilities in order to assess the adequacy of hysterectomies. Such strategies are crucial to protect gynaecologists from the false sense of safety of defensive medicine and to put the patient at the centre of a treatment decision.
Recent scientific evidence shows that the number of hysterectomies is far greater than those needed. In the last 10 yr in Italy (and not only), the number of hysterectomies performed for cervical intraepithelial neoplasia (CIN) has also increased in a worrying way (1). However, the recommendations of the World Health Organization (2) and the most recent European guidelines (3) make this clear that in the case of CIN 1 of a histological high-grade squamous intraepithelial lesion (i.e., CIN 2-3) not exceeding the basal membrane, and of invasive cervical cancer up to stage T1a1, conservative diagnostic-therapeutic management should be preferred. In the above cases, hysterectomy constitutes an overtreatment as the risk of complications of surgery outweighs any health benefit to the patient. In some circumstances, hysterectomy can be a (partially or totally) resolving tool for CIN: microinvasion, histologically confirmed recurrent high-grade CIN, co-presence of other uterus pathologies that worsen the overall clinical-gynaecological picture, such as prolapse, fibroids, pelvic inflammatory disease and endometriosis (4). Except in these cases, less invasive methods for the treatment of CIN 1 and of histological high-grade squamous intraepithelial lesion are recommended.
The reasons behind the inadequate use of hysterectomy (i.e., in the absence of specific indications) are attributable both to the insufficient scientific updating of some gynaecologists, and to the spread of the phenomenon of defensive medicine, also called defensive medical decision-making (5). The actions of the gynaecologist are no longer guided by scientific evidence but motivated primarily by litigious concerns. The increased incidence of medico-legal litigation in the healthcare sector inevitably instils in the surgeons’ minds the fear that their decisions may be challenged. Namely, gynaecologists end up practicing more than the necessary hysterectomies (even in the absence of specific indications) in fear that using less invasive procedures may be challenging in case of an unlikely progression of the neoplasm.
The increase in unnecessary hysterectomies has significant medical-legal repercussions. First, a hysterectomy is an invasive surgery associated with a risk of mortality of 0.4% and a much higher risk of intra- and post-operative complications (1). Complications and harms of an unnecessary hysterectomy can expose the doctor and/or healthcare facility to a greater risk of legal defeat. In fact, both will be called to justify the use of an avoidable invasive procedure. In addition, a hysterectomy can also cause mental damage in women (6).
The uterus preservation can help to preserve fertility, and that is why, in primis, this issue has been discussed here, but uterus is not an organ exclusively aimed at procreation but is, in all respects, an indispensable part of the sexual identity of the woman, regardless of age. Therefore, it is urgent to implement the quality of the scientific update of gynaecologists; it is also essential to carry out a standardized control of healthcare facilities in order to assess the adequacy of hysterectomies. Such strategies are crucial to protect gynaecologists from the false sense of safety of defensive medicine and to put the patient at the centre of a treatment decision.
Type of Study: Letter to Editor |
Subject:
Medical Ethics in Reproductive Sciences
References
1. Ciavattini A, Di Giuseppe J, Marconi C, Giannella L, Delli Carpini G, Paolucci M, et al. Hysterectomy for cervical intraepithelial neoplasia: A retrospective observational multi-institutional study. Int J Gynaecol Obstet 2022; 159: 679-688. [DOI:10.1002/ijgo.14233] [PMID] [PMCID]
2. World Health Organization. WHO guidelines for treatment of cervical intraepithelial neoplasia 2-3 and adenocarcinoma in situ. Switzerland: World Health Organization Press; 2014.
3. Cibula D, Pötter R, Planchamp F, Avall-Lundqvist E, Fischerova D, Haie-Meder Ch, et al. The European Society of Gynaecological Oncology/European Society for Radiotherapy and Oncology/European Society of Pathology Guidelines for the Management of Patients with Cervical Cancer. Virchows Arch 2018; 472: 919-936.
https://doi.org/10.1007/s00428-018-2362-9 [DOI:10.1007/s00428-018-2380-7] [PMID]
4. Berek JS. Berek & Novak's gynecology. 16th Ed. Philadelphia: Wolters Kluwer Health; 2019.
5. Cioffi A, Cioffi F. A culture of openness and defensive medicine. Health Aff 2019; 38: 1411-1412. [DOI:10.1377/hlthaff.2019.00737] [PMID]
6. Laughlin-Tommaso SK, Satish A, Khan Z, Smith CY, Rocca WA, Stewart EA. Long-term risk of de novo mental health conditions after hysterectomy with ovarian conservation: A cohort study. Menopause 2020; 27: 33-42. [DOI:10.1097/GME.0000000000001415] [PMID] [PMCID]
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