Dr. James Spies is an interventional radiologist at Georgetown University Hospital, where he has been on the faculty since 1997. For the last seven years, he has been studying and pioneering an important new treatment for fibroids known as uterine fibroid embolization. In this interview, Dr. Spies discusses the nature of his specialty and the promise of the treatment to which his practice is devoted.
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Fibroids1: How did you decide on your specialty?
Dr. Spies: I’m an interventional radiologist, so I do procedures. I got interested in that at the end of my internship. In those days, radiologists weren’t the most respected physicians in the hospital. They were considered eight-to-five doctors. But most of the clinicians had tremendous respect for one radiologist where I did my internship. He was the procedures radiologist and he was very well-respected. Every doctor said, "If you’re going to be a radiologist, be one like him." So I decided to go into interventional radiology.
Fibroids1: Can you make the distinction between interventional radiology and other kinds of radiology for us?
Dr. Spies: Interventional radiologists are really the surgeons of radiology. We do procedures that take the place of surgical procedures. We use imaging guidance—a CT scan or another test—to guide us in passing small instruments into an organ, which may allow us to treat or drain the organ. It’s essentially an image-guided surgical specialty. We work in a room that looks like an operating room, we scrub in, but we do minimally-invasive procedures that don’t leave patients with large scars or long recovery.
Fibroids1: What do you feel is your greatest contribution to interventional radiology?
Dr. Spies: To be honest, I don’t think I’ve made a great contribution to the field. I’ve dedicated most of my recent years to uterine fibroid treatment and research and I think our group has made contributions to our knowledge in that area. I became interested in that topic based on the early report in 1997 on uterine embolization by Scott Goodwin from UCLA. It probably did not hurt that my wife is a gynecologist and she served as a tutor for me in this area.
I’ve spent most of the last seven years treating patients and doing research in embolization. We have sought to detail patient outcomes: How well are symptoms controlled? What impact does this have on the quality of life? How frequent are complications? We need the answers to these kinds of questions and this has been our focus.
One of the most rewarding parts of this type of procedure and research is the impact that we have on patient’s symptoms. For example, most patients presenting to us are healthy but for one thing: fibroids and symptoms associated with them. So in a way, this is a kind of perfect procedure to evaluate outcomes. Many have significant bleeding and cramping; others will have pressure, discomfort, and urinary symptoms. If you were to take those symptoms away, most would be normal. If you effectively treat the fibroids with embolization or other therapies, a very high percentage will have their menstrual symptoms return to normal, and their pressure symptoms go away. So you take someone who has really terrible periods and make them have normal periods, and it completely changes their life. We’ve been able to measure those things using psychometric techniques such as questionnaires. This type of data provides a scientific confirmation of outcome. In daily practice, this is the equivalent to a follow-up patient coming into the office and saying, "My life is returned to me. I am so much better." It’s great.
Fibroids1: How did your wife influence your interest in the procedure?
Dr. Spies: In the early days of this, I could talk about it to her. She actually thought it was a crazy idea initially. As time went by, she was able to put this procedure into context with other fibroid therapies. It has given me a deeper appreciation of the skills of gynecologists and the value of a collaborative relationship with them. My wife is an excellent gynecologist and she has a very good sense of what should be done in treating patients. This has been a great influence on my approach to these patients.
One additional thing she has taught me: uterine fibroid embolization isn’t for every patient. I’ve learned that some patients who might want to have an embolization might be better off having an operation. What’s essential in this type of practice is understanding and being interested in health issues related to women, and my wife helped me learn those things.
Fibroids1: What kind of fibroid patient might be a better candidate for a different kind of treatment?
Dr. Spies: First, women without symptoms should not be treated, as a general rule. Once a patient has symptoms, it’s appropriate to get treatment. The decisions about treatment choices should be based on patient-related issues: her age, her interest in future childbearing, her interest in retaining her uterus and other personal concerns she might have. Once these have been considered, we assess the extent of the fibroids; their size number and location within the uterus.
A woman who would like to become pregnant within two years after the procedure may be better off having a myomectomy. In general, to carry a child, it is best to have the most normal uterus that you can at the time you conceive, because you want to have room for the baby to develop. Some women are not good candidates for myomectomy, however. If a patient has had prior myomectomy or has too many fibroids, or if they are not surgically accessible, embolization may be preferred.
Anatomically, a very large fibroid that projects into the abdominal cavity might best be removed by surgery because usually it shrinks more slowly after embolization. There is scar tissue formation, and a slightly higher risk of complication with less potential benefit. At the other end of the spectrum, a patient with a small fibroid inside the cavity of the uterus may possibly be removed with a hysteroscope (a telescope-like instrument advanced into the uterus through the vagina under anesthesia). Fibroids that are part of the uterine wall cannot be as easily done that way.
Fibroids1: What do you see as the most important new trends in gynecology or radiology?
Dr. Spies: In fibroids, there are a number of new therapies that are being evaluated, including new medical therapies and ablation techniques, such as high frequency ultrasound. As a field, interventional radiology is constantly evolving. Uterine fibroid embolization, for example, basically didn’t exist in the U.S. before 1997, and now 10,000 women a year are being treated. I think we’ll see gene-therapy innovations in the years ahead. In addition, there are now many regional therapies to treat tumors with heat, cold or microwaves.
Fibroids1: How do you expect your practice to be different in five years?
Dr. Spies: I plan to continue to focus on fibroid embolization and other fibroid interventions. For many in Interventional Radiology, our field will continue to evolve; there will be more cancer-related therapies and fewer vascular procedures. Most of us will continue to move toward independent clinical practice. I think it’s likely that Interventional Radiologists will separate themselves from other radiologists and become more like a surgical subspecialty. I think that’s a national trend.
Fibroids1: Have you seen any trends in the acceptance of uterine fibroid embolization among gynecologists?
Dr. Spies: I don’t think it’s universal by any means; I think there’s a certain segment of the gynecology community that’s even a little hostile to it. People tend not to like or are afraid of things they don’t understand. What I think these individuals miss is that while hysterectomy is a perfect solution for the patient who chooses it, there are many patients who would like to avoid the operation. But I think that many gynecologists are beginning to accept this procedure. The majority of our patients are now referred to us by their gynecologists. These same gynecologists are gaining experience in hysteroscopy and myomectomy, providing uterine-sparing treatments. The trend is toward uterine preservation and this is gaining acceptance among many gynecologists.
Fibroids1: For our readers who may be looking for a radiologist, how would you recommend they find a good one?
Dr. Spies: You should use the physician locator on this website, which will list physicians who perform the procedure. The subspecialty society, the Society of Interventional Radiology, has a website, www.sirweb.org, which also has a physician locator. Another way is to ask your gynecologist to recommend someone who has had experience with the procedure and is doing a good job.
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