NEW YORK (Reuters Health) – African-American, Hispanic-American and Asian-American women are more likely to undergo abdominal myomectomy than white women, according to a new analysis of data from the American College of Surgeons’ National Surgical Quality Improvement Program (NSQIP).
The study also found higher rates of morbidity for black women after abdominal myomectomy, and for Asian women after laparoscopic myomectomy.
“Our study identified racial disparities in surgical fibroid management whereby minority women were substantially more likely to undergo myomectomy via laparotomy as compared to their Caucasian counterparts,” Dr. Divya K. Shah of the University of Pennsylvania in Philadelphia, the senior author of the study, told Reuters Health by email. “Moreover, morbidity after myomectomy was greater in African American and Asian American women despite accounting for overall health and fibroid burden.”
African-American women are known to have a higher incidence of leiomyomas than white women, while their disease burden and morbidity after myomectomy is also greater, Dr. Shah and colleagues note in Obstetrics & Gynecology, online July 10. But less is known about fibroids and myomectomy approaches and outcomes in women of other ethnicities.
To investigate, the researchers retrospectively analyzed NSQIP data on more than 8,000 women who underwent myomectomy in 2012-2015, including 2,533 whites, 3,359 African Americans, 664 Asian Americans and 700 Hispanic Americans.
Compared with white women, African-American women had twice the odds of undergoing abdominal myomectomy (adjusted odds ratio, 1.9; 95% confidence interval, 1.7 to 2.0), as did Asian American women (aOR, 2.3; 95% CI, 1.8 to 2.8). Hispanic American women had 50% greater odds of abdominal myomectomy (aOR, 1.5; 95% CI, 1.2 to 1.9).
The procedure took significantly longer in African Americans and Asian Americans than in whites, and African Americans and Hispanic Americans had longer hospital stays than whites. African-American women had twice the odds of requiring repeat surgery and being admitted to the hospital (OR, 2.3; 95% CI, 1.0 to 5.3; and OR, 1.9; 95% CI, 1.1 to 3.3, respectively), but this risk was not increased in Asians or Hispanics compared to whites.
Previous research has identified ethnic disparities in the use of minimally invasive techniques for hysterectomy, the authors note, and the new findings show the same is true for myomectomy.
“The etiology of the increased incidence of leiomyomas in African American women remains unknown. Studies are still examining various hypotheses including genetic factors, dietary factors, psychosocial stress, and environmental exposures,” Dr. Shah told Reuters Health. “Though the size and associated power of the ACS-NSQIP dataset enabled us to identify this health disparity, further elucidation of the etiologies of the disparity will require higher fidelity data, likely a more local or institutional level.”
Dr. Elizabeth A. Stewart, chair of the division of reproductive endocrinology at the Mayo Clinic in Rochester, Minnesota, told Reuters Health by phone, “It’s a very nice study. I think that we need better studies in this field and this is a good step in the right direction.”
“There is some evidence that African-American women have greater morbidity following surgery, even after attempts to control for extensive disease,” she said. “The issue I have with that is the measure that is available to control for extensive disease is rather limited in an administrative database.”
She noted that the coding used in the study defines high myoma burden as more than 250 grams, but women with extensive fibroids may have uteruses weighing more than a thousand grams. The issue of whether minimally invasive myomectomy is the best choice for women with very large fibroids is controversial, she added.
“Most people agree that the complications are lower for laparoscopic procedures than for operative procedures, but the second issue is that with laparoscopic procedures for very large fibroids you have to find a safe way to remove them,” Dr. Stewart said. Concerns have been raised about cancer risks associated with morcellation, she added, so this procedure is being used less frequently.
“Women need to be brought into the process and have some shared decision-making when they decide on a therapy,” she said. “We can’t tell whether the women in this study chose their specific therapy or whether they were offered a limited number of therapies.”
The finding of increased morbidity for Asian-American women has not been shown before, she said, and should be studied further.
“There are some ongoing studies that will help us understand better about surgical therapies,” Dr. Stewart said. “One of the big ones is a fibroid registry called Compare US that is recruiting women from centers across the U.S. to look at outcomes of surgical therapies.”
These studies include more complete baseline information, she added, such as the size of a woman’s fibroids and her symptoms.
Obstet Gynecol 2018.