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Join Nikki Keefe, an interventional radiologist, as we delve into the complexities of uterine fibroids and the disparities in treatment access. Despite uterine fibroids affecting up to 70 percent of women and causing severe symptoms like heavy menstrual bleeding, pelvic pain, and infertility, many, especially Hispanic and rural patients, are unaware of uterine artery embolization (UAE), a minimally invasive and effective treatment option. Nikki will discuss the various treatment options, the benefits of UAE, and the significant barriers to awareness and access, highlighting the urgent need for improved education and health care equity.

Nikki Keefe is an interventional radiologist.

She discusses the KevinMD article, co-authored by Matt Patetta, MD, Maureen Kohi, MD, Gloria Salazar, MD, Kira Griffith, and Josh Walker, “Overcoming disparity in access to uterine artery embolization.”

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Transcript

Kevin Pho: Hi, and welcome to the show. Subscribe at KevinMD.com/podcast, and get CME for this episode by clicking on the CME link in the show notes. Today we welcome Nikki Keefe. She’s an interventional radiologist. Today’s KevinMD article is “Overcoming disparity in access to uterine artery embolization.” Nikki, welcome to the show.

Nikki Keefe: Thank you so much for having me, Kevin.

Kevin Pho: So we’ll talk about the article in a little bit. First off, just briefly share your story and journey.

Nikki Keefe: I’m an interventional radiologist at the University of North Carolina. I hail from Buffalo, New York, so it’s a little bit different down here. We chose to study the health disparities that patients undergo when it comes to treatment of their fibroids. Fibroids are super common and affect up to 80 percent, more common in African-American women than white women or Hispanic females. But it’s very common, and the most common procedure performed these days is a hysterectomy, but there’s a lot of other options for them. And that’s what we sought to evaluate, is those disparities among patient care for the treatment of their fibroids.

Kevin Pho: Perfect. So let’s jump straight into that article. It’s titled “Overcoming disparity in access to uterine artery embolization.” Now before going to an article, just to get everyone on the same page, just give us a 30-second primer in terms of what a uterine fibroid is.

Nikki Keefe: Perfect. So a uterine fibroid is a soft tissue benign tumor within the uterus. It’s just an abnormal growth there. It can cause a bunch of different symptoms that we categorize into bleeding and bulk. So the bleeding related symptoms, heavy menstrual cycles, pain associated with menses, intermenstrual bleeding, it can be really devastating to a lot of patients. Bulk related symptoms, due to just the size of the fibroids pushing on adjacent structures, frequent urination, constipation, back pain, abdominal pain, bloating, those kinds of things. It can really affect a female’s quality of life.

Kevin Pho: All right. In terms of potential next steps forward, and that intersection of course between interventional radiology and the treatment of uterine fibroids.

Nikki Keefe: So there’s a lot of treatment options. The first being you can do nothing. A lot of people will live with them, and either they don’t know they have them or they’ve just been living with them so long they’re used to it.

You’ve got medical therapy options. Most of them are a form of birth control or medication that will help decrease the bleeding, but you have to take it forever until you reach menopause, because fibroids are hormonally dependent.

There’s endometrial ablation, where they go and they burn the uterine lining in order to stop the bleeding, but it only helps with the bleeding related symptoms.

Uterine artery embolization, which is of course what I do and my focus here, which is a minimally invasive treatment in order to block the blood supply to the fibroids to decrease their size.

There’s myomectomy, where they can cut out the fibroids. That can be done either through a laparoscopic approach or a transvaginal approach. And then there’s ultimately a hysterectomy, where they remove the entire uterus plus or minus the fallopian tubes or ovaries to treat the fibroids.

Kevin Pho: And to focus on uterine embolization, who would be the right candidates, and what type of fibroids would be more amenable to that approach?

Nikki Keefe: Yeah, we’ve done a lot of research over the past 20 years to evaluate that exact question. And historically there are a lot of patients that may not have qualified, but the vast majority of patients these days qualify for uterine fibroid embolization. They can have gigantic fibroids, they can have small little fibroids, they can be pushing on the endometrial canal or on the other side of the uterus towards the parametrium, they can be hanging off into the uterine cavity. All of those fibroids qualify for uterine artery embolization.

The only caveat being that for patients that desire preservation of their fertility, we don’t have great data on that. It’s just so hard to study prospectively those patients. While we’ve seen plenty of patients get pregnant afterwards and have successful pregnancies, we just don’t have the data to say it’s the equivalent to a myomectomy yet.

Kevin Pho: So what exactly is that procedure like for the patient?

Nikki Keefe: The vast majority of practitioners these days go through the artery in the wrist. We take the long winding route down to the artery that goes towards the fibroids. There’s one on each side, each uterine artery. Sometimes they’ll go through the artery in the groin instead, if you don’t qualify for the artery in the wrist. We put tiny little particles into the arteries that supply the fibroids to block off the blood supply. Some people will put lidocaine in the arteries, some people do a nerve block, some people just do postoperative medications in order to help manage the postoperative pain.

The recovery for a uterine artery embolization is about one week, so pretty short. And patients can expect to see their bleeding symptoms significantly improved by three months, and their bulk related symptoms significantly improved by six months. So it does take a little bit of time, because we’re talking about shrinking down those fibroids. I liken it to, as if you plucked a grape from a vine, it’s going to turn into a raisin. It’s never going to disappear, it’s still there, but it’s not functional. So it takes time, but we do see really good results with preservation of the uterus. We have data that shows at ten years out we’re preserving more than 60 percent of uteruses for patients, which, you know, a lot of people don’t want that big surgery that comes with a hysterectomy.

Kevin Pho: And in terms of outcomes, how does that approach compare to some of the other treatment modalities, say myomectomy or hormonal therapy?

Nikki Keefe: Yeah, we have great outcomes, that at two and five years post UAE the outcomes are equivalent to myomectomy and hysterectomy in terms of quality of life postoperatively.

Kevin Pho: All right. So in your KevinMD article, it’s titled “Overcoming disparity in access to uterine artery embolization.” So talk more about that article.

Nikki Keefe: Yeah, so what we look to evaluate is how uterine artery embolization is faring in comparison to these other procedures over the past ten years. And really demographically, is it equivalent for patients who are of different socioeconomic status, different regions within the country, different racial and ethnicity status, insurance, income, all of those different things. And we did see some areas of disparity, which was, you know, sad to see, but really allows us to focus on those areas in particular.

So if I start off with the background, we see about 80 percent of women get a hysterectomy for fibroids, about 20 percent get a myomectomy, less than 1 percent get an endometrial ablation, and only about 2 percent get a uterine artery embolization. So it’s really not a common procedure yet, even though our national society has been pushing and advocating for this procedure for patients.

We do see differences between non-Hispanic whites, non-Hispanic blacks, and Hispanic patients. Blacks account for the vast majority of patients that have fibroids, and yet we see that they are actually more common to get a uterine artery embolization than other procedures, than a myomectomy or hysterectomy, which I found very interesting.

Across income levels it’s pretty equivalent. Across insurance levels we’re seeing an increased number of patients in the Medicare population getting inpatient procedures, with a decrease in private insurance. And I think that’s because a lot of patients are getting outpatient uterine artery embolizations. Our study was really focused on the inpatient setting, so we’re seeing a lot more Medicare patients in the inpatient setting.

But the most interesting one to me was in the rural-urban setting. So the vast majority of patients get their procedures done in an urban teaching environment, whereas only 1 percent of patients get it done in a rural center. And there’s a lot of patients out there in the rural setting that just aren’t getting access to the care that they deserve.

Kevin Pho: So in terms of this procedure, what is the penetration of this being done, say at a community hospital that could be more amenable to a rural setting?

Nikki Keefe: Yeah, so about 20 percent of the proportion of procedures that are being performed are done in a community setting, not in an academic center. So still a fair amount of patients that are being able to get this procedure done.

Some of the differences that, because our data was based on inpatients, a lot of rural or urban non-teaching hospitals or community-based hospitals, a lot of private practices will do their procedures in an outpatient setting, so we’re not capturing that portion. But there are other studies that have captured that and are showing that, you know, the proportions are still the same. It’s still a lot less people that are getting UAE done compared to myomectomy or hysterectomy.

Kevin Pho: So in terms of the racial disparities when it comes to access to UAE, what are some potential explanations that can lead to those findings?

Nikki Keefe: So we found that Hispanic patients were actually less frequently offered or underwent uterine artery embolization compared to others. That may be due to language barriers, where you know, patients don’t get access to care or they just don’t understand quite what’s going on, due to lack of translators or appropriate language.

But also, you know, a lot of it has to do with community, where you know, one person gets a procedure done, they love the results, they tell all of their family and their friends. And if we don’t capture the Hispanic population, then it doesn’t spread as much by word of mouth as it would in communities.

Kevin Pho: So I have a question in terms of the pathway to get to an interventional radiologist. Typically, I’m a primary care physician, internal medicine. If I see someone with symptomatic fibroids, I will send them to a gynecologist, and intuitively that would lead me to think that they will do some type of gynecology-based procedure. Now in general, are they the ones who would refer people to UAE?

Nikki Keefe: That’s a great question, and something that I think within the entire spectrum of IR we have challenges with, because we don’t necessarily own the patient, like gynecology will own a fibroid patient, and you know, urology will own a prostate patient with BPH. It’s, you know, very similar type of disease pathology.

But typically the patient will go to their gynecologist, they’ll get an endometrial biopsy for increased bleeding, they’ll get an ultrasound that evaluates the fibroids, and the gynecologist will talk to them about their treatment options. We have seen a lot of patients come through our clinic that say that they were never even offered a uterine artery embolization as an option.

So we do get a lot of patients, we have an amazing relationship with our gynecologists at UNC, so we get a lot of referrals straight from our gynecologist. But we also get a lot of self-referrals, where they come straight from their primary care, their internal medicine doctor, what have you, after they found out about it through word of mouth.

Kevin Pho: All right. So in terms of these disparities, whether it’s racial disparities or disparities as it relates to insurance, tell us some of the next steps that you see to increase access to UAE.

Nikki Keefe: I think it’s not really a problem of IR alone. Racial and economic and location, geographic disparities are a problem for medicine as a whole. You know, you have to have the interventional radiologist in this rural community in order to have the procedure available to that patient. So that’s one of the biggest challenges that people face.

But another way that we can help with that is through multidisciplinary clinics, having a joint clinic with GYN where we see all of the fibroid patients together, so they’re getting that evaluation from both GYN and interventional radiology simultaneously, hearing all of their options, making sure that all of the t’s are crossed and the i’s are dotted for their procedure. You know, that can really benefit the patients, that they understand everything of what’s going on and have all of their options available to them.

Kevin Pho: Now, is there an example of such a multidisciplinary approach perhaps that’s not in an academic medical center? Are you aware of a story, or tell us a story where you’ve seen that?

Nikki Keefe: We had that at the University of Virginia where I trained, where we had that multidisciplinary clinic, where we met with patients at the same exact time in the gynecology clinic. It was like once a month, every Monday I think, with our gynecologist. I don’t know of one offhand in the private practice or non-academic setting, but I’m sure that exists.

Kevin Pho: So tell us the future of uterine artery embolization. What do you see something that’s coming down the pipeline? What can we expect regarding this therapeutic modality?

Nikki Keefe: Yeah, I think that like I said, over the last 20 years we’ve done extensive research on this to really try and demonstrate that it is a viable procedure for patients with fibroids. And not just fibroids, but also adenomyosis, we’re showing good results with that as well.

Our society has worked really hard on promoting fibroid awareness and allowing people to understand all of their treatment options. I think it’s just going to take time of working with referring doctors, particularly in the primary care community and with OB/GYN doctors, and then also patient-directed marketing, so that they understand their options, in order to really reach out to a broad number of patients.

And I think some of our marketing should be focused on the Hispanic community and on those underserved areas, whether they are rural areas or the non-academic hospitals, to really try and focus on those other patients that we may be missing.

Kevin Pho: Now, for the patients who may be listening to you now, and even for me as a primary care physician, what kind of questions should patients ask themselves, what kind of questions should I ask patients, to determine whether a uterine artery embolization may be right for them?

Nikki Keefe: So I think that we as a community need to do better in educating patients and our referring providers. When a patient comes to a primary care doctor with heavy bleeding, with bulk related symptoms, I think it’s important for the primary provider to perhaps just start off with the basic ultrasound to see exactly what’s going on. If they have fibroids, of course they should be referred to a gynecologist. In no way should IR supplant gynecologists, right, because they still need to work up with an endometrial biopsy and those other kinds of things.

But I really want the patients to understand that it’s a multidisciplinary approach. Surgery, and a hysterectomy in particular, is not your only option. You know, there are ways that we can do minimally invasive, whether it’s myomectomy or uterine artery embolization, and to not just be satisfied with hysterectomy as the only option.

Kevin Pho: We’re talking to Nikki Keefe. She’s an interventional radiologist. We’re talking about the KevinMD article “Overcoming disparity in access to uterine artery embolization.” Nikki, we’ll end with some of your take-home messages that you want to leave with the KevinMD audience.

Nikki Keefe: Thanks again for having me, Kevin. So my take-home message is, for patients, uterine artery embolization is a great option for fibroids and adenomyosis. For clinicians, don’t hesitate to reach out to interventional radiology, just if it’s a question, can we do this, is the fibroid too big, is it pushing in an area that’s unsafe. You know, we do a lot of combined procedures as well, where we do preop fibroid embolization for planning for myomectomy or hysterectomy in order to minimize blood loss for patients. So we really like that multidisciplinary approach, and don’t forget to reach out to your friendly IR.

Kevin Pho: Nikki, thank you so much for sharing your perspective and insight, and thanks again for coming on the show.

Nikki Keefe: Thank you.