Uterine Artery Embolisation in 2024: Why does it still feel like 2005?

It has been 19 years since the EMMY trial was published and since then we have seen continued publication of high-quality trial data on the efficacy of Uterine Artery Embolisaton (UAE) including REST, FEMME, and meta-analyses. We have now considered pregnancy after UAE, there is continuing evidence for UAE to treat adenomyosis, and there are even trials assessing its role in treating pain secondary to endometriosis. We can now say with even more certainty than ever, that UAE provides women with an effective and durable treatment for their symptoms, at low cost to society.

So, why does it feel like even after 19 years has passed we are still facing issues with patient access?

I have been thinking about this a lot. I recently reached out to a nearby womens’ health service to discuss UAE for their patients and after waiting 3 weeks for a reply, got a 2 line email which can be summarised as “no thanks”. Can you imagine how I felt to think that a hospital was offering fibroid treatments to their catchment area, and yet that entire group of patients still didn’t have access to UAE? I then engaged with a very supportive womens’ health service at a different hospital and discussed UAE with key stakeholders. To find an interested and receptive gynaecology group was refreshing. While these examples are contrasting, no doubt you as a reader of this blog will resonate with this variation, or find that your colleagues are somewhere in the middle. The reality is that even busy and successful UAE programs are the exception and not the rule. We have the data, we have been talking about it amongst ourselves, but the message still isn’t getting out to patients.

Whose fault is this? Gynaecologists? Ours? Someone else?

I don’t think we can expect gynaecologists to keep up to date with the latest data and trials for UAE, as this is an IR treatment - this is our job. I also don’t think we can just hang a sign on our door saying “UAE done here” and expect that patients will be fighting to get through the door. Recognition of benign diseases and recognition of womens’ health issues both don’t get the attention they deserve, it won’t be the same as it is for cancer patients who find their way through to us easily due to the time-critical nature of these treatments.

Several of my recent discussions made it clear to me that gynaecologists still don’t know what IR is or what we do. I would add to this list; governments, hospitals, and administrators too. They all think we primarily report scans and occasionally perform a procedure. They don’t know that we run our own surgical lists, outpatient clinics, and manage patients as clinicians. Gynaecologists also don’t know the UAE outcome data like we do and how it is rapidly evolving over time. To me, the best way to work within a multidisciplinary team is to embrace collaboration. We can work in a tripartite arrangement with gynaecologists and general practitioners, with the patient as the focus - this is what embodies patient-centred care.

IRs have made some great steps since publication of EMMY, with specialisation in some countries, clinical practice, ward-based care, and research. However, in my experience we generally haven’t sufficiently evolved with the times, and we haven’t integrated ourselves enough into the face of frontline healthcare. We have to embrace the modern patient - one who uses google and Chat-GPT whilst getting feedback from Facebook groups. We must use these tools to educate patients, both at a local level, and through major societies like CIRSE. In my opinion we should advocate at every forum possible, share patient stories, engage with (social) media, publish our clinical outcomes, and continue to push the boundaries with new research. Patients have to see the face of IR as the experts in this role, not gynaecologists and GPs as the clinical experts and IRs only fulfilling the faceless role of an adjunct technician.

Whatever you decide to do as an IR is your choice, but if we all keep doing the same thing we are currently doing, then I can guarantee you that in another 19 or 20 years, we will be having the same discussions about poor access.

The government is a contributor

In spite of what we have done and plan to do, there is no doubt that the efforts of many are being hamstrung by red tape. In my opinion, the biggest barrier to taking the next steps to improve access is specialist recognition for IR as a full clinical specialty, and this must happen worldwide. Top-down changes like mandated NICE clinical practice guidelines have been shown to work for improving evidence-based access. But this is only one part of the solution. The solution is realistically multifactorial and the mandate is for everyone to work on all these challenges simultaneously.

When considering how you are going to tackle this, consider the most effective strategy in game theory - be nice and merciful, but do not be a pushover. We should stand up for our specialty and our potential future patients. And to be honest, all these changes resonate for advocacy of many of our treatments, not just UAE.

Happy embolising my IR friends and colleagues, let’s not be still be discussing poor access to UAE treatments in 20 years’ time.