text: Occult Uterine Sarcoma and Leiomyosarcoma: Incidence of and Survival Associated With MorcellationRaine-Bennett, Tina MD, MPH; Tucker, Lue-Yen BA; Zaritsky, Eve MD; Littell, Ramey D. MD; Palen, Ted PhD, MD; Neugebauer, Romain PhD; Axtell, Allison MD; Schultze, Peter M. MD; Kronbach, David W. MD; Embry-Schubert, Julia MD; Sundang, Alvina MBA; Bischoff, Kimberly MSHA; Compton-Phillips, Amy L. MD; Lentz, Scott E. MDObstetrics & Gynecology: January 2016 - Volume 127 - Issue 1 - p 29–39 doi: 10.1097/AOG.0000000000001187 Contents: Original Research Free Abstract In Brief Author InformationAuthors Article OutlineOutline Article MetricsMetrics OBJECTIVE: To estimate the incidence of occult uterine sarcoma and leiomyosarcoma in hysterectomies for leiomyomas and the risk associated with their morcellation. METHODS: We conducted a population-based cohort study. All uterine sarcomas from 2006–2013 in an integrated health care system were identified. Age- and race-specific incidences of occult uterine sarcoma were calculated. Kaplan-Meier survival analysis was performed. Crude and adjusted risk ratios of recurrence and death associated with morcellation at 1, 2, and 3 years were estimated using Poisson regression with inverse probability weighting. RESULTS: There were 125 hysterectomies with occult uterine sarcomas identified among 34,728 hysterectomies performed for leiomyomas. The incidence of occult uterine sarcoma and leiomyosarcoma was 1 of 278 or 3.60 (95% confidence interval [CI] 2.97–4.23) and 1 of 429 or 2.33 (95% CI 1.83–2.84) per 1,000 hysterectomies. For stage I leiomyosarcoma (n=111), eight (7.2%) were power and 27 (24.3%) nonpower-morcellated. The unadjusted 3-year probability of disease-free survival for no morcellation, power and nonpower morcellation was 0.54, 0.19, and 0.51, respectively (P=.15); overall survival was 0.64, 0.75, and 0.68, respectively (P=.97). None of the adjusted risk ratios for recurrence or death were significant except for death at 1 year for power and nonpower morcellation groups combined (6/33) compared with no morcellation (4/76) (5.12, 95% CI 1.33–19.76, P=.02). We had inadequate power to infer differences for all other comparisons including 3-year survival and power morcellation. CONCLUSION: Morcellation is associated with decreased early survival of women with occult leiomyosarcomas. We could not accurately assess associations between power morcellation and 3-year survival as a result of small numbers. Morcellation is associated with decreased early survival of women with occult leiomyosarcomas. Division of Research, Kaiser Permanente Northern California, Oakland, California; the Institute for Health Research, Kaiser Permanente Colorado, Denver, Colorado; the Permanente Federation, LLC, Kaiser Permanente, Oakland, the Departments of Obstetrics and Gynecology and Gynecology Oncology, The Permanente Medical Group, Oakland and San Francisco, California; Colorado Permanente Medical Group, Denver and Aurora, Colorado; and Southern California Permanente Medical Group, Los Angeles, California. Corresponding author: Tina Raine-Bennett, MD, MPH, Division of Research, Kaiser Permanente Northern California, 2000 Broadway, 3rd Floor, Oakland, CA 94612; e-mail: firstname.lastname@example.com. Financial Disclosure The authors did not report any potential conflicts of interest. Presented at The Health Maintenance Organization Research Network (HMORN) annual meeting, March 11–13, 2015, Long Beach, California, and The Kaiser Permanente National Quality Conference, June 2–4, 2015, Denver, Colorado. The authors thank Betty Suh-Burgmann, MD, and Howard Moffett, MPH, for editorial assistance and Linda Radler, MBA, Gerri Salazar, CTR, and Fiona Sinclair, PA-C, MHS, for assistance with data acquisition. Abstract MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES Supplemental Digital Content Uterine sarcomas, malignancies of the myometrium or endometrial connective tissue, occur rarely and are associated with poor prognosis.1–3 They may be indistinguishable from uterine leiomyomas, which is the most common indication for hysterectomy in the United States.4 The use of laparoscopic hysterectomy and power morcellation has substantially reduced surgical morbidity, but concern over peritoneal dissemination of occult uterine sarcoma in which there was no preoperative or operative suspicion for malignancy has prompted calls for reevaluation of the incidence of occult uterine sarcoma and risk associated with morcellation.5–7 In November 2014 the U.S. Food and Drug Administration issued a warning against use of power morcellators in the majority of women undergoing hysterectomy for uterine leiomyomas.8 The current data on the incidence of uterine sarcoma among women undergoing hysterectomy for leiomyomas are based primarily on studies from single-center or tertiary-based practices and include a broad range of publication dates (1990–2012), small numbers of patients (101–1,429), and sarcomas (0–7) per study.9,10 In addition, interpretation of existing studies of the risk associated with power morcellation of occult sarcomas is challenging because of small numbers of sarcomas and morcellation procedures per study and methodology flaws.11 To fill gaps in the literature, we conducted this study to: 1) estimate the age- and race-specific incidence of occult uterine sarcoma among women undergoing hysterectomy for suspected benign leiomyomas; and 2) assess the association of morcellation and length of survival among women with leiomyosarcoma. Back to Top | Article Outline MATERIALS AND METHODS This population-based cohort study was performed using data abstracted from Kaiser Permanente's electronic health record and regional claims systems. Kaiser Permanente is an integrated health care delivery system in which health plan members obtain all care from Permanente physicians and allied health professionals with few exceptions. The three regions included in this study, northern California, southern California, and Colorado, served approximately 3.1 million adult women annually during the study period. Oversight and approval to conduct this study were provided by the institutional review board of the Kaiser Foundation Research Institute. We identified all women 18 years and older who underwent hysterectomy from January 1, 2006, to December 31, 2013, at a Kaiser Permanente-owned, contracted, or referral hospital with a principal discharge diagnosis of leiomyomas based on International Classification of Diseases, 9th Revision and Current Procedural Terminology coding of surgery indication. Women with a new diagnosis of uterine sarcoma during the same time period were identified through the Kaiser Permanente regional cancer registries using the International Classification of Diseases for Oncology codes (Appendix 1, available online at http://links.lww.com/AOG/A728). All sarcomas that were incident at hysterectomy or at the time of myomectomy that subsequently led to a hysterectomy during the study period were included in our analyses. Sarcomas that were incident at a biopsy only and hysterectomy was not performed were excluded. The pathology reports were reviewed and malignancies were categorized into histopathology subgroups based on the 2014 World Health Organization classification of uterine mesenchymal malignancies as follows: 1) leiomyosarcomas (including epithelioid and myxoid types); 2) low-grade endometrial stromal sarcomas; and 3) high-grade endometrial stromal sarcomas, undifferentiated uterine sarcomas, including very rare miscellaneous mesenchymal malignancies (rhabdomyosarcomas and perivascular epithelioid cell tumors).12–14 We excluded mixed epithelial–mesenchymal tumors (carcinosarcoma and adenosarcoma).15,16 Clinical and surgical information on sarcomas was obtained by chart review. Hysterectomies were categorized as: 1) no morcellation; 2) power morcellation defined as use of an electronic device at laparoscopy; and 3) nonpower morcellation defined as intraoperative tissue disruption with a scalpel or cautery at laparotomy or vaginal hysterectomy (including facilitating myomectomy) or myomectomy done at a separate procedure that led to the hysterectomy. Uterine sarcomas were considered occult if the surgeon did not report a preoperative suspicion for malignancy in the preoperative clinic notes, admitting history, and physical or operative note. They were considered nonoccult if known or suspected malignancy was documented before the hysterectomy as a result of suspicious or positive endometrial or other biopsy, suspicious imaging (reported by the interpreting radiologist), or other reason, including cancer found at a separate myomectomy procedure. American Joint Committee on Cancer criteria for staging were used and were based on the findings at the original surgery unless postoperative imaging in occult sarcomas revealed distant metastases making them stage IV. Follow-up information including adjuvant treatments, time to and site of recurrence, death, and latest medical contact was also obtained by chart review. Information on vital status was obtained from the tumor registries, which utilize standard reporting sources including state death certificate and Social Security databases. Analyses were performed using SAS 9.3. P values were considered statistically significant at <.05. We examined characteristics of uterine sarcomas by histopathology and morcellation subgroups using χ2 tests or Fisher exact tests for categorical variables and Wilcoxon-Mann-Whitney test for continuous variables. We calculated age- and race–ethnicity-specific incidence rates for occult uterine sarcoma. Proportions and 95% confidence intervals (calculated using Wald or Wilson Score method) were reported per 1,000 hysterectomies by histopathology, age, and race–ethnicity subgroups. Poisson regression with robust variance was used to estimate the risk ratios of occult uterine sarcoma across age groups (adjusted for race–ethnicity) and across race–ethnicity groups (adjusted for age).17 We used the Kaplan-Meier method to estimate the unadjusted cumulative 3-year disease-free and overall survival probabilities by morcellation group for sarcomas with disease confined to the uterus (American Joint Committee on Cancer stage I). For the disease-free survival analysis, women were censored at last clinical encounter or disenrollment from the health plan, the time of death resulting from all causes, or the administrative end of study (May 31, 2015). For overall survival, women were censored at the administrative end of study. We evaluated differences in disease-free and overall survival among morcellation groups using the log-rank test. Propensity score methods were used to evaluate the effect of morcellation on recurrence and death while adjusting for baseline confounding factors using Poisson regression fitted by inverse probability weighting estimation.18 We estimated the propensity scores using logistic regression models to predict morcellation group with the covariates age (younger than 50, 50–59, or 60 years or older), race–ethnicity (white, Hispanic, African American, or Asian or other), American Joint Committee on Cancer substage (IA, tumor size 5 cm or less or IB greater than 5 cm), occult sarcoma (yes or no), body mass index ([calculated as weight (kg)/(height [m])2] 24.9 or less, 25–34.9, or 35 or greater), uterine weight (500 or less, 500–1,000, or greater than 1,000 g), and Charlson Index of comorbid conditions score greater than 2 (yes or no).19 The set of baseline covariates was reduced using the Akaike information criterion.20 For disease-free and overall survival, at 1, 2, and 3 years, to contrast risks of different types of morcellation, we generated two separate Poisson regression models fitted by inverse probability weighting estimation comparing: 1) nonpower morcellation with no morcellation; and 2) power and nonpower morcellation groups combined with no morcellation. Adjusted risk ratios for power morcellation compared with no morcellation could not be estimated as a result of small numbers (n=8). The adjusted risk ratios for recurrence and death at 1, 2, and 3 years were compared with their crude analog obtained based on unweighted Poisson regression. Back to Top | Article Outline RESULTS From 2006 to 2013, 93,153 women underwent hysterectomy; 34,603 (37.2%) had a principal discharge diagnosis of leiomyomas. Among hysterectomies for leiomyomas, 45.8% were abdominal, 44.7% laparoscopic, and 9.5% vaginal and 20.1% vaginal. We identified 321 new uterine sarcomas, of which 293 were in patients who underwent hysterectomy (Fig. 1). Twenty-eight uterine sarcomas were excluded because they were identified at the time of biopsy but did not undergo a hysterectomy as a result of advanced disease or other comorbidities. Of the 293 hysterectomies, seven were preceded by separate myomectomy procedures (four abdominal, two hysteroscopic, and one vaginal myomectomy of a prolapsing leiomyoma) in which uterine sarcomas were identified postoperatively. There were no uterine sarcomas identified at myomectomy that did not go on to hysterectomy. Fig. 1 Less than half (42.7%) of uterine sarcomas were occult before hysterectomy (Fig. 1). Among the 187 stage I sarcomas, 94 (50.3%) were occult. Power and nonpower morcellation occurred in only a small number of stage I leiomyosarcomas (8 [7.2%] and 27 [24.3%]) and low-grade endometrial stromal sarcomas (8 [17.0%] and 6 [12.8%]); no high-grade endometrial stromal sarcomas were morcellated. Characteristics of uterine sarcomas that underwent hysterectomy are presented in Table 1. The majority (65.9%) of women were age 50 years and older and half (50.9%) were postmenopausal. Patients with low-grade endometrial stromal sarcomas were significantly more likely to be younger (P=.005), premenopausal (P=.006), and American Joint Committee on Cancer stage I (P=.003). Leiomyosarcomas (47.1%) and low-grade endometrial stromal sarcomas (53.2%) were significantly more likely to be occult than high-grade endometrial stromal sarcomas (18.6%) (P<.001). Table 1 The incidence of occult uterine sarcoma and leiomyosarcoma among women with hysterectomy for leiomyomas was 1 of 278 or 3.60 (95% confidence interval [CI] 2.97–4.23) and 1 of 429 or 2.33 (95% CI 1.83–2.84) per 1,000 hysterectomies, respectively (Table 2). The risk of occult uterine sarcoma and leiomyosarcoma adjusted for race–ethnicity in women aged 50 years and older was significantly greater compared with younger women. The risk of occult low-grade endometrial stromal sarcomas and high-grade endometrial stromal sarcomas in women aged 60 years and older adjusted for race–ethnicity was significantly greater compared with younger women. Table 2 Characteristics and follow-up information on stage I uterine sarcomas by histopathology subgroup and morcellation status are presented in Table 3. Aside from the significant differences in surgical route and other procedures performed that would be expected in hysterectomies with morcellation (power and nonpower groups combined) compared with no morcellation, there were no significant differences in surgical characteristics. Median follow-up months for leiomyosarcomas, low-grade endometrial stromal sarcomas, and high-grade endometrial stromal sarcomas were 35.1 (interquartile range 21.1–62.9), 51.3 (interquartile range 34.6–77.7), and 29.9 (interquartile range 9.8–59.1), respectively. There were no significant differences by morcellation group for leiomyosarcoma (P=.15) and low-grade endometrial stromal sarcomas (P=.76) and there was minimal loss to follow-up. Although the proportion of recurrences was similar for leiomyosarcomas with and without morcellation, leiomyosarcomas without morcellation were significantly less likely to have abdominal recurrences compared with leiomyosarcomas with morcellation (41.2% compared with 72.2%, P=.03) (Table 3). Table 3-a Table 3-b Kaplan–Meier survival plots were generated for stage I leiomyosarcoma by morcellation groups but not for low-grade endometrial stromal sarcomas and high-grade endometrial stromal sarcomas because of the small number of events and absence of morcellation procedures, respectively. The unadjusted probability of 3-year disease-free survival for stage I leiomyosarcomas with no morcellation, power morcellation, and nonpower morcellation was 0.54 (95% CI 0.42–0.64), 0.19 (95% CI 0.01–0.54), and 0.51 (95% CI 0.30–0.69), respectively. Although the plots suggest decreased probability of survival for power morcellation, there was no significant difference among all groups (P=.15) or between power morcellation and no morcellation (P=.29) or between nonpower morcellation and no morcellation (P=.88) (Fig. 2A). A The unadjusted probability of 3-year overall survival for stage I leiomyosarcoma for no morcellation, power morcellation, and nonpower morcellation groups was 0.64 (95% CI 0.52–0.74), 0.75 (95% CI 0.31–0.93), and 0.68 (95% CI 0.46–0.83), respectively; there was no significant difference among all groups (P=.97) or between power morcellation and no morcellation (P=1.0) or between nonpower morcellation and no morcellation (P=1.0) (Fig. 3A). A The crude and adjusted risk ratios of recurrence at 1, 2, and 3 years comparing power, nonpower, and power and nonpower morcellation groups combined to no morcellation are presented in Figure 2B–D. The crude risk ratios comparing power morcellation with no morcellation at 1 and 3 years were 2.38 (95% CI 1.05–5.38, P=.04) and 1.88 (95% CI 1.50–2.37, P<.001), respectively. All other risk ratios for recurrence had 95% CIs that included 1 and were not significant. The crude and adjusted risk ratios of death at 1, 2, and 3 years comparing power, nonpower, and power and nonpower groups combined to no morcellation are presented in Figure 3B–D. The crude and adjusted risk ratios comparing power and nonpower morcellation groups combined to no morcellation at 1 year were 3.45 (95% CI 1.04–11.44, P=.04) and 5.12 (95% CI 1.33–19.76, P=.02), respectively. All other risk ratios for death had 95% CIs that included 1 and were not significant. The crude risk ratio for death comparing power morcellation with no morcellation at 1 year approached significance at 4.75 (95% CI 1.03–22.0, P=.05). Back to Top | Article Outline DISCUSSION This study within a diverse, community-based U.S. population confirms uterine sarcomas are rare and occur more commonly in older women. It also shows less than half were occult. Our estimate of the incidence of occult leiomyosarcoma of 1 in 429 among women having hysterectomies for leiomyomas probably overestimates the incidence because we did not capture in the denominator women with hysterectomies with a principal discharge diagnosis of abnormal bleeding when leiomyomas was listed as a secondary diagnosis. Our estimates of the incidence of occult leiomyosarcoma are not directly comparable with the previous estimates by the U.S. Food and Drug Administration (1/498 women undergoing hysterectomy or myomectomy for presumed benign leiomyomas) and Pritts et al (1/1,700 women undergoing surgeries in retrospective studies and 1/8,300 in prospective studies) because these studies were meta-analyses in which inclusion criteria for leiomyosarcomas and the denominators varied widely across studies included.9,21 Our survival analyses do not demonstrate significant differences in the unadjusted 3-year disease-free and overall probability of survival among stage I leiomyosarcomas with power or nonpower morcellation and those with no morcellation; however, clinically significant effects cannot be ruled out as a result of small numbers. The crude and adjusted risk ratios for death at 1 year, however, were significantly increased for the power and nonpower morcellation groups combined compared with no morcellation indicating that morcellation is associated with decreased early survival. We may not have demonstrated a corresponding significantly increased risk of recurrence at 1 year as a result of better ascertainment of mortality status through cancer registry databases or alternatively there may have been differential survival associated with recurrences for the power and nonpower morcellation groups combined compared with no morcellation. Although the significantly increased crude risk ratios of recurrence at 1 and 3 years for power morcellation compared with no morcellation are highly suggestive of an adverse effect of power morcellation, we cannot rule out the possibility of confounding. Although the total number of uterine sarcomas in this case series is the largest that we are aware of from a community-based U.S. population, the number of leiomyosarcomas with power morcellation was too small to calculate adjusted risk ratios or make inferences about the risk of power morcellation. However, it is plausible that power morcellation would be equally as harmful as nonpower morcellation. The lack of demonstration of a significantly increased adjusted risk ratios for recurrence or death at 3 years for the power and nonpower morcellation groups combined may be the result of poor outcomes as time elapses in leiomyosarcomas without morcellation or, alternatively, lack of power to detect differences at 3 years as a result of the smaller sample size with 3 years of follow-up. The upper bounds of the CIs for the adjusted risk ratios of recurrence and death at 3 years for the power and nonpower morcellation groups combined compared with no morcellation (1.77 and 2.32, respectively) provide a guide of the range of potential adverse risk of morcellation. Survival data from our series provide more representative information on the risk associated with morcellation than recent reports by Perri et al, Park et al, and George et al.3,7,22–24 These studies have important methodologic flaws that lead to bias, which most likely overestimate the adverse effect of morcellation including: 1) selection bias associated with referral populations with unknown background incidence of leiomyosarcoma; 2) inclusion of hysterectomies with disease beyond the uterus; 3) use of comparison groups that lacked laparoscopic or vaginal hysterectomies that did not undergo morcellation; and 4) lack of specification of types of morcellation. Our study has several strengths. The integrated health care system and comprehensive electronic health records enabled capture of hysterectomies performed, comprehensive identification of patients with uterine sarcoma, specific histopathology, morcellation, and clinical outcomes with minimal loss to follow-up. Our study also has limitations. We also may not have had sufficient power to detect differences in the incidence of occult uterine sarcomas by race. There was no central pathology review. We could not control for mitotic index, because although elevated mitotic activity sufficient for diagnosis of leiomyosarcoma was specified in the pathology reports, the amount was not always specified. Finally, we were not able to estimate uterine sarcoma incidence at myomectomy given only seven sarcomas that were incident at myomectomy over 8 years. We hope our data on the estimated incidence of occult uterine sarcoma in combination with the demonstrated association of morcellation with decreased early survival for women with leiomyosarcomas may be useful to patients and health care providers who wish to weigh the risks against the known benefits of minimally invasive surgery.5,6 Back to Top | Article Outline REFERENCES 1. Nordal RR, Thoresen SO. Uterine sarcomas in Norway 1956–1992: incidence, survival and mortality. Eur J Cancer 1997;33:907–11. Cited Here... | PubMed | CrossRef 2. Brooks SE, Zhan M, Cote T, Baquet CR. Surveillance, epidemiology, and end results analysis of 2677 cases of uterine sarcoma 1989–1999. Gynecol Oncol 2004;93:204–8. Cited Here... | PubMed | CrossRef 3. Tropé CG, Abeler VM, Kristensen GB. Diagnosis and treatment of sarcoma of the uterus. A review. Acta Oncol 2012;51:694–705. Cited Here... | PubMed | CrossRef 4. Wright JD, Herzog TJ, Tsui J, Ananth CV, Lewin SN, Lu YS, et al.. Nationwide trends in the performance of inpatient hysterectomy in the United States. Obstet Gynecol 2013;122:233–41. Cited Here... | View Full Text | PubMed | CrossRef 5. Nieboer TE, Johnson N, Lethaby A, Tavender E, Curr E, Garry R, et al.. Surgical approach to hysterectomy for benign gynaecological disease. The Cochrane Database of Systematic Reviews 2009, Issue 3. Art No.: CD003677. DOI: 10.1002/14651858.CD003677.pub4. Cited Here... 6. Walsh CA, Walsh SR, Tang TY, Slack M. Total abdominal hysterectomy versus total laparoscopic hysterectomy for benign disease: a meta-analysis. Eur J Obstet Gynecol Reprod Biol 2009;144:3–7. Cited Here... | PubMed | CrossRef 7. George S, Barysauskas C, Serrano C, Oduyebo T, Rauh-Hain JA, Del Carmen MG, et al.. Retrospective cohort study evaluating the impact of intraperitoneal morcellation on outcomes of localized uterine leiomyosarcoma. Cancer 2014;120:3154–8. Cited Here... | View Full Text | PubMed | CrossRef 8. UPDATED laparoscopic uterine power morcellation in hysterectomy and myomectomy: FDA Safety Communication. 2014. Available at: http://www.fda.gov/MedicalDevices/Safety/AlertsandNotices/ucm424443.htm. Retrieved June 1, 2015. Cited Here... 9. U.S. Food and Drug Administration. Quantitative assessment of the prevalence of unsuspected uterine sarcoma in women undergoing treatment of uterine fibroids. 2014. Available at: http://www.fda.gov/downloads/MedicalDevices/Safety/AlertsandNotices/UCM393589.pdf. Retrieved August 20, 2014. Cited Here... 10. Bojahr B, De Wilde RL, Tchartchian G. Malignancy rate of 10,731 uteri morcellated during laparoscopic supracervical hysterectomy (LASH). Arch Gynecol Obstet 2015;292:665–72. Cited Here... | PubMed | CrossRef 11. Bogani G, Cliby WA, Aletti GD. Impact of morcellation on survival outcomes of patients with unexpected uterine leiomyosarcoma: a systematic review and meta-analysis. Gynecol Oncol 2015;137:167–72. Cited Here... | PubMed | CrossRef 12. Robert J, Kurman EA, editors. WHO classification of tumours of female reproductive organs. 4th ed. Lyon (France): International Agency for Research on Cancer; 2014. Cited Here... 13. Tavassoli FA, Devilee P, editors. Pathology and genetics of tumours of the breast and female genital organs. Lyon (France): International Agency for Research on Cancer; 2003. Cited Here... 14. Lee CH, Nucci MR. Endometrial stromal sarcoma—the new genetic paradigm. Histopathology 2014;67:1–19. Cited Here... | View Full Text | PubMed 15. Sreenan JJ, Hart WR. Carcinosarcomas of the female genital tract. A pathologic study of 29 metastatic tumors: further evidence for the dominant role of the epithelial component and the conversion theory of histogenesis. Am J Surg Pathol 1995;19:666–74. Cited Here... | View Full Text | PubMed | CrossRef 16. Friedlander ML, Covens A, Glasspool RM, Hilpert F, Kristensen G, Kwon S, et al.. Gynecologic Cancer InterGroup (GCIG) consensus review for mullerian adenosarcoma of the female genital tract. Int J Gynecol Cancer 2014;24(suppl 3):S78–82. Cited Here... | View Full Text | PubMed | CrossRef 17. Spiegelman D, Hertzmark E. Easy SAS calculations for risk or prevalence ratios and differences. Am J Epidemiol 2005;162:199–200. Cited Here... | View Full Text | PubMed | CrossRef 18. Hernán MA, Robins JM. Estimating causal effects from epidemiological data. J Epidemiol Community Health 2006;60:578–86. Cited Here... | View Full Text | PubMed | CrossRef 19. Charlson ME, Pompei P, Ales KL, MacKenzie CR. A new method of classifying prognostic comorbidity in longitudinal studies: development and validation. J Chronic Dis 1987;40:373–83. Cited Here... | PubMed | CrossRef 20. Cole SR, Hernán MA. Constructing inverse probability weights for marginal structural models. Am J Epidemiol 2008;168:656–64. Cited Here... | View Full Text | PubMed | CrossRef 21. Pritts EA, Vanness DJ, Berek JS, Parker W, Feinberg R, Feinberg J, et al.. The prevalence of occult leiomyosarcoma at surgery for presumed uterine fibroids: a meta-analysis. Gynecol Surg 2015;12:165–77. Cited Here... | PubMed 22. D'Angelo E, Prat J. Uterine sarcomas: a review. Gynecol Oncol 2010;116:131–9. Cited Here... | PubMed | CrossRef 23. Perri T, Korach J, Sadetzki S, Oberman B, Fridman E, Ben-Baruch G. Uterine leiomyosarcoma: does the primary surgical procedure matter? Int J Gynecol Cancer 2009;19:257–60. Cited Here... 24. Park JY, Kim DY, Kim JH, Kim YM, Kim YT, Nam JH. The impact of tumor morcellation during surgery on the outcomes of patients with apparently early low-grade endometrial stromal sarcoma of the uterus. Ann Surg Oncol 2011;18:3453–61. Cited Here... | PubMed | CrossRef Supplemental Digital Content AOG_127_1_2015_11_03_RAINEBENNETT_15-1176_SDC1.pdf; [PDF] (26 KB) Back to Top | Article Outline© 2016 by The American College of Obstetricians and Gynecologists. Published by Wolters Kluwer Health, Inc. All rights reserved. Article Outline Abstract MATERIALS AND METHODS RESULTS DISCUSSION REFERENCES Supplemental Digital Content Source Occult Uterine Sarcoma and Leiomyosarcoma: Incidence of and Survival Associated With Morcellation Obstetrics & Gynecology127(1):29-39, January 2016. Full-Size Email + Favorites Export View in Gallery Email to a Colleague Colleague's E-mail is Invalid Your Name: (optional) Your Email: Colleague's Email: Separate multiple e-mails with a (;). Message: Thought you might appreciate this item(s) I saw at Obstetrics & Gynecology. Send a copy to your email Your message has been successfully sent to your colleague. Some error has occurred while processing your request. Please try after some time. Email to a Colleague Colleague's E-mail is Invalid Your Name: (optional) Your Email: Colleague's Email: Separate multiple e-mails with a (;). Message: Thought you might appreciate this item(s) I saw at Obstetrics & Gynecology. 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How to Use Vista Buttons Menu Generator
- Now let's set the submenu buttons web-behavior. That is, set their Link properties. To set the submenu link, select the submenu item by clicking it and then enter the link address in the "Link" field on the Properties toolbox.
Another way to set the submenu's link is to select it and then click the "Select page" button on the Properties toolbox. Open dialog will appear, in which you can select the page you would like to link to. This page's address will then appear in the "Link" field.
- Also, you can assign link target attributes for each submenu item. This will define where a linked page will be opened in your Web-browser. For example "_blank" attribute will open the linked page in new browser window. Note that link target attribute act exactly like the Target attribute of the <a> tag in HTML. To set submenu link target attribute, just select the submenu item and then either choose one of the predefined values from the "Link target attributes" list on the Properties toolbox or enter your own value (window/frame name, where the linked page should be opened). Learn more about link target attributes from the user guide.
- Create 1-state, 2-state, 3-state and 3-state toggle buttons Use images for icons, backgrounds of submenus and items. Using images you can create menus entirely based on graphics. Create both horizontal and vertical menus and submenus with any amount of menus on one page. Insert any HTML code inside the menu item - be it a form or a picture, a flash-object or a text. This ability allows you to create various menus of any complexity.
SupportPlease contact Customer Support at (please include template name in the message title)
- ".. I'm wondering if there is a possibility to create my own Icon Themes for the Web Design Buttons to extend the already built-in with my own icon-sets?"
- "I can add as many levels as I want in the button generate program , but just one submenu button per level in the ..." Radio Button And Horizontal
- "..How can I set up Vista Buttons dreamweaver extension?"
- "..The submenu of a menu buttons do not appear in front of a flash movie, it is allways under it. "
- "..Isn't there a way to insert two different website menus saved as different projects into one webpage at different locations?"
- ".. Can site buttons be added to my existing web pages and how easy is it to update once it is installed and do? "


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- 09 November, 2018
Insurance – protecting what you have
General insurance is a "boring" subject and not a matter we have discussed much over the last few years of Realise Your Dream, however, protecting what you have is just as important in your retired life as it was in your working life So, here a couple of thoughts to...Read More
- 01 November, 2018
Is it time to apply for the aged pension? Pt. 2
Some weeks ago, I wrote a blog called 'Is it time to apply for an age pension?', which looked at the complexities and frustration of the application process. Some readers have asked the question – when should a person look at whether they would qualify for an age pension? For...Read More
- 25 October, 2018
Change for good or change for the sake or change?
With the rather significant swing against the Coalition at last weekends' by-election in the Sydney seat of Wentworth, we turn our attention to next year's Federal Election, expected to be held around May 2019. If present trends are an indication of the future, we will see a change of government...Read More
- 18 October, 2018
Is it time to apply for the age pension?
On 1 February 2019, many people will turn 65 years and 6 months. You may be asking why is this important? For most of us, this date will mean very little, however, for those who do turn 65 years and 6 months, it will mean that they have reached age...Read More
- 03 October, 2018
Royal Commission – do we need another?
I have been in Vietnam for the last few weeks, blissfully ignorant for a short period of time of all the dramas which go on in the world. When I left the country at the beginning of September, the "Royal Commission into Misconduct in the Banking, Superannuation and Financial Services"...Read More
- 20 September, 2018
Dealing with the unexpected
Life has a habit of throwing us a curve ball every now and then – something unexpected appears out of the blue and we have to deal with it. On more than one occasion, I am sure you have found yourself having to deal with something unexpected. If you are...Read More


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Sports & Leisure Activities
Results: 14
7425 Sechelt Inlet Road, Sechelt, BC V0N 3A4
1792 Alberni Street, Vancouver, BC V6J 1C9
Slocat Harbour Tours offers three scheduled daily tours and sunset cruises through beautiful Pender Harbour. It's an affordable family adventure through one of the most scenic and protected harbours on the West Coast.
103 - 622 Hough Road, Gibsons, BC V0N 1V4
1051 Gibsons Way, Gibsons, BC V0N 1V7
1161 Sunshine Coast Highway, Gibsons, BC
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Access Coalition Webinar Series 2019
Energy Access: the role of civil society in the area of productive uses This webinar will focus on productive uses of energy (PUE) and the role of civil society organizations. Read more...
30 April 2019, 12 p.m. CEST, (Registration link)
The Energy Efficiency Project Resource Center offers project-relevant energy efficienca (EE) documents to the global energy community. It is designed to assist in making EE project planning and implementation more efficient and sustainable as well as to facilitate knowledge exchange across organizations and regions.
The EE Project Resource Center is a living repository and its success depends on contributions from the global energy community. We look forward to your contributions! Learn more on how you can contribute here.
If you have any questions, please see the Help Section or contact the energypedia team.
This category has the following 12 subcategories, out of 12 total.
The following 130 pages are in this category, out of 130 total.


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Honduran president prepares for truth commission
On the eve of forming of a truth commission to investigate the cause of the June 28 Honduran coup, the country´s president, Porfirio Lobo, was in San José Monday to thank a leader of the reconciliation process, Costa Rican President Oscar Arias.
Arias, who served as a mediator in the Honduran conflict, is scheduled to leave office on Saturday, after completing his four-year term as president of Costa Rica. He opened his doors to the feuding parties when former Honduran President Manuel Zelaya was ousted on charges that he intended to amend the Constitution, which is an illegal act in Honduras.
"My primary motive for being here is to thank President Arias for his long hours in working towards reconciliation," the newly installed Honduran president said during a press conference at Costa Rica´s Casa Presidencial.
Lobo also spoke about the establishment of a truth commission in Honduras, which was part of the San José Agreement, a 12-point document that Arias introduced during the mediation process.
Although controversy is already gripping the creation of the commission – as some argue it´s better to let the details of the conflict remain buried – Lobo is determined to see it through.
"We can´t complete the reconciliation without knowing the truth," he said, explaining that his motive is not to point fingers, but to know what went wrong so that it doesn´t happen again.
"When I came into office, my commitment wasn´t to Zelaya or to (interim president Roberto) Micheletti, it was to the Honduran people and to the reconciliation process," Lobo said
For his part, Arias made another plug for international recognition of Lobo´s presidency, the legitimacy of which is still questioned by some countries. Arias called it "absolutely unacceptable" that international leaders have not re-embraced Honduras.
Other issues discussed during the meeting were the association agreement with Europe and Arias´ exit from Costa Rican politics.
You may be interested
International drug rehab in Costa Rica with the Costa Rica Treatment CenterThe Tico Times - April 24, 2019
Costa Rica Treatment Center understands the process of addiction recovery from personal experience. Their evidence-based treatment programs are engineered to…
Costa Rica meets with Inter-American Commission on Human Rights to discuss Nicaragua, Venezuela, indigenous rightsAlejandro Zúñiga - April 23, 2019
Costa Rica's Minister of Foreign Affairs, Manuel Ventura Robles, met with the Inter-American Commission on Human Rights (IACHR) this week…
Freed Nicaraguan prisoner tells of tortureAFP - April 23, 2019
One Nicaraguan guard pinned his hand to a table with his knee while another ripped out a nail with a…


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Social preferences and private provision of public goods: A 'double critical mass' model
First Online:
- 106 Downloads
- Citations
We set up an evolutionary game-theoretic model aimed at addressing the issue of local public good provision via direct commitment of voluntary forces (private donors and nonprofit providers) only. Two classes of agents are assumed to strategically interact within a 'double critical mass' model and we investigate the critical factors affecting the dynamic outcomes of such interaction. Further, we explore the conditions under which (what we term) 'evolutionary crowding-out/in' occurs, depending on agents' degree of opportunism, social comparison and positive selective incentives (such as subsidies given by the government to 'virtuous' citizens or nonprofits only).
KeywordsDouble critical mass Evolutionary crowding-out Privately provided public goods Prosocial emotions Social preferences
Unable to display preview. Download preview PDF.
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Blogs I Follow
Recent Posts
- Aldous Harding covers "Right Down The Line" by Gerry Rafferty
- Budget transparency at private universities: Some thoughts about SCU
- Why does SCU want to take the faculty unionization straight to the NLRB? Because they could reverse every unionization on every Jesuit and other "religious" university
- Tactics when confronting a Trump-appointee dominated NLRB: "three would-be unions withdraw petitions"
- When Loyola University A&S faculty tried to unionize, religious-ness became an issue…
Friends of African Village Libraries (I post regularly here)
- An error has occurred; the feed is probably down. Try again later.
Category Archives: United States
Want to understand the reparations issue? Nobody better than Prof. Sandy Darity to patiently and clearly explain
Cannot embed directly into WordPress, so here is the link: https://www.c-span.org/video/standalone/?458905-4/washington-journal-william-darity-discusses-reparations-campaign-2020
Posted in United States
Uber co-founder eyes downtown San Jose historic building
Uber co-founder and former chief executive Travis Kalanick's new realty investment enterprise has obtained a contract to purchase the old Hank Coca's Furniture store and Odd Fellows building at 82 E. Santa Clara St. The building became available after Leisure … Continue reading
Posted in San Jose
Small facts I always forget: US has no restrictions on dual citizenship
Anticipating Nov. 6 election when many of my fellow citizens will vote their preference to live under a right-wing autocracy that uses mass media to boil blood just because they are mad about a trans kid in Nebraska whose gender … Continue reading
Posted in United States
Recent experiences with minimum wages
A nice The New York Times story on Seattle that prompted this roundup (HT:Bill Sundstrom): "In their latest paper, which has not been formally peer reviewed, Mr. Vigdor and his colleagues considered how the minimum-wage increases affected three broad groups: … Continue reading
Some readings on the economics of private prisons
Here is a Brookings Institution report: "The 2016 Nobel prize-winner in Economics, Oliver Hart, and coauthors explained that prison contracts tend to induce the wrong incentives by focusing on specific tasks such as accreditation requirements and hours of staff training … Continue reading
Building housing in San Jose
My response to a friend and neighbor: "I have no problem with 3-4 story housing all along the corridors, throughout the city, and higher heights on larger lots like the old hospital site. So when the planner you quoted gave … Continue reading
Readings on immigration issues in the United States
A good The New Yorker introduction to very recent (October 2018) policy issue of naturalization of permanent residents (green card holders). Hanson, Liu and McIntosh on immigration to the US by low-skilled young workers. Abstract: From the 1970s to the … Continue reading


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We are Not a Network Marketing Company, but are the Largest Lead Vendor to the Network Marketing Industry. We are your one-stop-shop for the best Home Based Business and MLM leads! We provide our customers with the freshest, up-to-date leads and information in order to help you and your business succeed. All of our leads are highly qualified individuals that are interested in getting involved with a home based business. If you're looking to expand your business, we've got the leads and information you need! Our company is dedicated to supplying you and your business with the best leads possible! We understand you need a reliable and credible lead source and that's why we're here!
A long time friend that you lost touch with for the last 10 years gives you a call and asks to meet up. After meeting up and breaking the ice, he/she then introduces a new revolutionary product and how you stand to get rich by selling it. Throw in jargons like passive income and downlines, you suddenly realise you're beginning to be sucked into the dream they are selling.
The main reason why leading world companies create accounts in social networks is to attract traffic to landing pages and websites. YouTube's video hosting by the number of search queries is second only to the Google search engine, and you can attract some of this huge traffic flow to your site / landing page by simply posting your video (and related links to your web resources) on this hosting.
Skills – There are certain technical skills you need for whatever industry you are a part of, so it's important to develop those skills. Although, they are a small fraction of what your success will be predicated on. You must eventually learn to outsource the things that make the most sense to outsource, so that you can work on the business versus in the business.
Carl Rehnborg is credited as having started the multi-level marketing industry back in the 1930s. After learning about the benefits of dietary supplements in China, Rehnborg came back to the United States and started a company called The California Vitamin Company, which was later rebranded to Nutrilite. Six years after that rebranding, Rehnborg reorganized the company's structure and the way it sold products into what we know as MLM today.
A long time friend that you lost touch with for the last 10 years gives you a call and asks to meet up. After meeting up and breaking the ice, he/she then introduces a new revolutionary product and how you stand to get rich by selling it. Throw in jargons like passive income and downlines, you suddenly realise you're beginning to be sucked into the dream they are selling.
The overwhelming majority of MLM participants (most sources estimated to be over 99.25% of all MLM distributors) participate at either an insignificant or nil net profit.[12] Indeed, the largest proportion of participants must operate at a net loss (after expenses are deducted) so that the few individuals in the uppermost level of the MLM pyramid can derive their significant earnings. Said earnings are then emphasized by the MLM company to all other participants to encourage their continued participation at a continuing financial loss.[13]
Business Opportunity Seekers are in constant search of the latest, most effective money making opportunities. Whether you're marketing business opportunities or Multi Level Marketing, you need the hottest business opportunity seeker names available! Our Business Opportunity Seekers and Business Opportunity Leads will get you the response you are looking for.
Is Home Depot going to run a class on how to make submarine sandwiches? No. Makes no sense, right? Would people be attracted to that? Like that one I might attend. I like submarine sandwiches, they're pretty good. That I might attend but I'm going to go there and be like why am I in a building supply company? I'm not going to buy anything. It doesn't make sense.
Below is a screen shot of a program called Zennoa which l reviewed and was in the pre-launch stage. Google did not even know that program exists and ANY website could have ranked for that search term. There is really no point in wasting valuable time flogging dead horses. There is no need for another review of Empower Network, Vemma or those MLM ancestors … LOL.
Wellness based MLM's in particular are well positioned to help people retire with greater ease and success for two reasons. First, they create positive momentum. When people start to lose weight, have more energy, or receive compliments on the way the look, it builds momentum. They see, feel, and hear the benefits of their work paying off which encourages them to stick with the changes they are making. Second, there is a group effect. Many people struggle to develop and stick with a new health, diet, and exercise program on their own. But when they do it in a supportive community with others, it's much easier to get through the tough days and stay on track. Furthermore, by taking better care of yourself, you are in a position to leave a better legacy than money could ever provide.
If you want to go the technological route, it's not a bad idea to check out what is out there in lead generation software. You will be able to more effectively send e-newsletters, organize your contacts in a database, and exploit a variety of features which will help you to generate more network marketing sales leads. Implement these step by step, and before you know it you will have a well-developed marketing strategy that helps you to reach out to prospects in a more personalized way.
Now that companies can easily sell directly to their customers online, people look to social media to get their recommendations for products, and the popularity of subscription beauty boxes, not to mention the fact that there are so many retail stores even in the most far out suburbs, I don't see how the network marketing model is necessary anymore. The only people who defend them are the people who were trained to. This is because MLMs love to brainwash you into defending them against naysayers and demand you go on the offensive to anyone who might disagree. They may still have wide-eyed hope. It's sad and terrible. The sooner these pyramid schemes are declared illegal and go out of the business, the better off the world will be.
Business Opportunity Leads typically come from people who are either seeking to find a new business opportunity or those who are interested in creating a business opportunity. It is not uncommon for business opportunity leads to involve investors or those who have access to stock or funds that they would like to direct towards a more purposeful cause. Leads may also come from new businesses that are seeking to offer opportunities to prospective clients.
There is nothing new about people failing; yes, they fail – at lots of things. We could spend months trying to discover why people fail in their marriages, school, jobs, etc. Do I have compassion and feel for them when they can't make it work. Yes, of course! But I can't jump into their bodies and make choices and live their life for them. It's their choice – quit or find a way to keep going. MLM is a business and not everyone will succeed. Will I make money from my HARD EARNED customer base? Yes! Do I feel bad because I make a commission. No! EVERY business owner makes money off their employees – other wise they would not be in business. Do Brick and Morter Business Owners feel bad that they are making millions and they are paying their employees minimum wage??? Of Course Not. That is just the nature of business. So why are you feeling "bad" that you made money? Did you tell your recruits that they could do what you did to make money ? You see, there is a difference in selling a product to a customer and telling a person they can "get rich quick" and do nothing to get there. Those people will fail every time when they listen to such lies. hoilictictouch.com Get Oiled!
Don't just focus on the glowing reviews from distributors who are making $50,000 per month. You should also pay close attention to those people who never made any money and gave up after a few short months. Why did they give up? What are the common complaints from unsuccessful distributors? Answer these questions to gain insights into the MLM you're considering.
Leads should come in the form of people that are likely to work with you. When you get leads for free, they may not be targeted. That's okay though, you can target these people yourself, and it's free to do if you're willing to put some time into learning marketing. Don't just get a logo slapped together and act like you're an awesome company with all kinds of things you don't really have in place. However, you can work with leads that you target by learning to make a splash in places like review websites and other places people read more about companies.
This article was really informative and honest! I'm not presently involved in an MLM and I don't ever plan to be especially after reading this article and the comments below. Why? Well because of EXACTLY the kind of "networking" and "recruiting" that these companies and many of the people commenting on here are advocating. I have been bombarded on my facebook, and other social media from people I haven't spoken to or seen in years. Its becoming constant, and I am not on social media to make money. Roden and Fields, shakeology, some girl I went to high school with is now trying to get me to buy leggins from her. I have a cousin that I actively avoid now because he is constantly steering every single conversation to Herbellife and why I NEED it to be healthy. Jesus. Its just enough already. I'm all for empowering people, and I love the idea of earning an additional income to take care of your family or yourself. But I could not imagine alienating or even just annoying friends and family in order to make an extra dollar. What I dislike most is that many of those that are recruiting make it seem as if they recruiting you simply because they want to "help" you or provide you with an opportunity. They make it seem as if they are doing this out of the goodness of their hearts, when really the actual motivation is line their own pockets with more money, because the more people you recruit for your team, the more money you make. That feels dishonest and slimy to me. Unless I'm asking for "help" or an "opportunity" I wish people would assume that I don't need and am not interested in one!
Internet marketing lead generation is without doubt the best way for you to attract the most prospects possible to your business. The tricky part is how to effectively use network marketing lead generation without wasting a lot of time. You could spend hours just spinning your wheels online and not acquire near enough leads to justify the time. We'd like to share a few of our short- and long-term strategies for how to effectively make your business boom through network marketing lead generation.
The overwhelming majority of MLM participants (most sources estimated to be over 99.25% of all MLM distributors) participate at either an insignificant or nil net profit.[12] Indeed, the largest proportion of participants must operate at a net loss (after expenses are deducted) so that the few individuals in the uppermost level of the MLM pyramid can derive their significant earnings. Said earnings are then emphasized by the MLM company to all other participants to encourage their continued participation at a continuing financial loss.[13]
If you want to go the technological route, it's not a bad idea to check out what is out there in lead generation software. You will be able to more effectively send e-newsletters, organize your contacts in a database, and exploit a variety of features which will help you to generate more network marketing sales leads. Implement these step by step, and before you know it you will have a well-developed marketing strategy that helps you to reach out to prospects in a more personalized way.
On the part of the company who sells a certain product via MLM, the advantage is really huge. Imagine if you have an unknown product that came from the wilderness and nobody has really ever heard. Since you are an MLM type of guy, you made a simple conversation with a few of your neighbors and relatives and let them know about your newly discovered product.
Multi-level marketing companies are not required to release information about the average income of distributors in the United States. However, some MLMs do release this information in what is called an income disclosure statement. If you would like to see the amount of income gained by distributors on average for a specific MLM, search the company's name in Google + "income disclosure statement."
The structure of MLMs is very similar to a pyramid scheme. This doesn't mean that all MLMs are pyramid schemes, but some certainly are. Those interested in pursuing a career in multi-level marketing should do research before joining a particular MLM. Generally speaking, if the bulk of the money you stand to earn comes from recruitment rather than direct sales, it's wise to be very cautious.
Serving our clients since 2005, CustomLeads.net is your "one-stop shop" when it comes to Network Marketing Leads, Home Based Business Leads, and Business Opportunity Leads. We provide not only up-to-date lists and contacts to bring sales and affiliate building to your business, but we also provide you with highly qualified individuals who are truly interested in pursuing a work from home business. If you're looking for people who are interested in home based business opportunities, we have that information available for you.
Thank you for sharing your perspective on the Direct Sales/MLM companies. As a business owner and entrepreneur, there is often a lot of noise from many sources about what is the best way to grow and be of importance. One of the things I have learned and continue to learn is that we must really love what we do, believe in our offering, whether is it a product or service, and listen closely to our gut instincts. A business coach of mine once said being a prism is beautiful, but it is scattered light, focus on what you love. Another important thing to know for yourself , is that there are different learning styles. If you choose to join any company, MLM or otherwise, be clear with yourself how you best learn and thrive. Getting swept up in the cheering may feel good, and it may keep you motivated on some level, however, be clear on how do you retain knowledge and use it. If a company has a one size fits all approach, be very careful that you do not get swept away. Thank you again for sharing this information. It has helped me have another look at my goals and how to continue focusing on what I love to do.
How do you choose mlm leads that are genuinely interested in starting a home business, just like you? Where can you find an mlm lead generation company that takes you and your business seriously—one that actually cares about your success whether you are a leader with 50,000 people in your team or just starting out? You've come to the right place—a place where we make it easy.
Let's face it, whether you call it multi-level marketing, direct sales, or network marketing, the entire industry gets a bad rap. It's often labeled as a pyramid scheme or get rich quick scam, and frankly, there is ample evidence to approach it with caution. However, as I have studied trends in this business model, I have come to a very different conclusion. One that actually suggests that network marketing can play a crucial role in how well baby boomers and others transition into retirement.
MLMs are designed to make profit for the owners/shareholders of the company, and a few individual participants at the top levels of the MLM pyramid of participants. According to the U.S. Federal Trade Commission (FTC), some MLM companies already constitute illegal pyramid schemes even by the narrower existing legislation, exploiting members of the organization.[21] There have been calls in various countries to broaden existing anti-pyramid scheme legislation to include MLMs, or to enact specific anti-MLM legislation to make all MLMs illegal in parallel to pyramid schemes, as has already been done in some jurisdictions.[citation needed]
I'm surprised Rodan and Fields didn't make the list, considering they are the fourth largest premium skin care company with the top three being 50+year old companies, Estée Lauder, Lancôme & Clinique. We are North America's 4th largest and fastest growing premium skincare company, but we're not in stores, the top 3 — Clinique, Lancôme and Estée Lauder.
A few people do make big money from MLMs. And these people are often trotted out in promotional videos, celebrated at annual events, and very publicly 'rewarded' with prizes like prestigious cars (although these 'prizes' aren't as generous as they first appear – you simply get a discount on the lease which you must take out in your own name, and if your sales fall, the discount ends…). You also need to promote the company on the car they 'give' you.
Great article and you nailed it regarding purchasing leads. I tried a few times talking with various people over the phone but none committed. I often wonder how the greats like Dexter Yager and Bill Britt (both amway reps) built their businesses to such a large magnitude without the use of social media. I certainly believe social media has made building network marketing businesses much easier than back in the day.
We can deliver: We are generating three types of leads that are focused towards the network marketing industry. The following is a weekly breakdown: 3,000 telephone interviewed, 1,500 Long Form surveyed leads and 4,500 Real Time Short Forms. With over 40,000 real-time leads generated every month. We are the leader in lead generation for network marketers.
To find quality high converting mlm leads you need to compare different mlm companies and find one that has proven results from those in the field. You are looking for a company where no matter what mlm or network marketing business you are involved in will be able t give you quality leads. For finding leads on your own you need to advertise, create websites, write articles and some how get more and more people to come to you for information. Creating your own leads is a far more wise decision then spending your hard earned money on people who haven't even asked for what you are offering. You can't even compare that to a person who specifically fills out a form and requests more information about your business. Stop wasting your time targeting the wrong MLM leads for your business (opportunity seekers – people who have only proven that they know how to fill out a form) and target the right leads to your business "proven business opportunity buyers" (other networkers - people who have already proven that they can and will spend money on a business opportunity.
Not all MLM companies are created equal. Many see an initial burst of success followed by a gradual tapering off of profits, causing them to collapse and go out of business. MLM companies that succeed have sound business models, both for those who run the company and for those who sell product and recruit new sales agents. There are many sites devoted to MLM rankings, creating lists of companies likely to provide a return on investment to sales agents interested in the industry.
Multi-level marketing, abbreviated as MLM, also called pyramid selling, network marketing and referral marketing, is a controversial marketing strategy for the sale of products and/or services where the revenue of the MLM company is derived from a non-salaried workforce (also called participants, and variously known as "salespeople", "distributors", "consultants", "promoters", "independent business owners", etc) selling the company's products/services, while the earnings of the participants is derived from a pyramid-shaped commission system.
We have been accumulating this BizOpp Buyers file for a few years now. So we have combined them all together to come up with a huge list of over 1 Million of our best Business Opportunity leads. Each record has name, postal address, phone, email address, date, time, IP address. This list combines the scope and price of a mega database with the targeting of our bizopps seekers lists.
We strive to verify all of our data and to also ensure your best experience we also offer this lead Replacement policy. If you receive a Disconnected, wrong number or bad email address, we will replace them. Simply complete a support ticket with the leads in question and we will add fresh business opportunity leads to your account. No Questions Asked.. WE Stand Behind Our LEADS!
Here is how they mostly work: You sign up and pay the buy-in fee to receive your startup kit, and then you start clogging everyone's social media feeds about your new venture and beg your friends and family to join you on your "journey to financial success". You host a bunch of fake parties and wine tastings or worse, you meet up one-on-one to catch up and the whole thing turns out to be nothing more than a demo and sales pitch where you guilt your friends into buying stuff they don't want or need. After you subject them to that, you then try to recruit them to join your team of consultants, or whatever term your particular MLM uses.
Don't just focus on the glowing reviews from distributors who are making $50,000 per month. You should also pay close attention to those people who never made any money and gave up after a few short months. Why did they give up? What are the common complaints from unsuccessful distributors? Answer these questions to gain insights into the MLM you're considering.
Our MLM Autoresponder Leads are fresh & responsive, and they have specifically stated that they are seeking information on starting an internet home-based business. They are high quality leads from 100% Opt-in sources, and are never generated through email or spam marketing. We guarantee that you will be the exclusive holder of the Leads for your primary Opportunity, never re-selling the same lead to anyone else who is promoting the same MLM or Network Marketing business. We also guarantee that we will not sell the leads more than 2 times total.
To really understand the beauty of MLM, everyone must understand the fact that as a human being, we all have potentials as well as limitations. No matter how much we've reached and used our individual potential, our outcome or whatever result we may be able to produce in a period of 24 hours (if we no longer sleep which is impossible) is still limited based on our individual capability being alone. As they said, "two is always better than one." Is it "two heads are better that one?" I am not really sure but I know you get my point.
Wow Collette! I'm a new Advocate with doTERRA, as is my wife. She wanted to start using oils to get our family off of medications as much as possible (and now we mostly are!) We chose doTERRA over all the other oils companies because of the process in which they farm and make their oils as well as the great culture they seem to exude. We just felt called to them.
Don't worry you will learn how to build your Business with my Cost Effective ways of getting leads for MLM guide. In this process do yourself a favor by telling "I can always quit tomorrow" Every Single Day. Why you should follow this guide? Because you owe Financial Freedom and Success you dreamed for. One last thing I want to tell you is that there is no rocket science in enticing or persuading people who are not interested in your business opportunity. Many of them are either simply looking for information or they don't have initial investment. Remember for Internet Marketing to work, Learn Copy writing skills. Enticing Leads through your copy comes with good copy writing skills.
Below is a screen shot of a program called Zennoa which l reviewed and was in the pre-launch stage. Google did not even know that program exists and ANY website could have ranked for that search term. There is really no point in wasting valuable time flogging dead horses. There is no need for another review of Empower Network, Vemma or those MLM ancestors … LOL.
The reason I started Apache Leads way back in 2003 was that I was a Diamond level distributor for a San Diego based MLM company and had quite a large business. None of my associates had any access to leads, so that's how we got started. The demand for leads grew so fast that I had to focus on getting quality, affordable leads in ever increasing numbers.
Anyone handling a network marketing business needs effective MLM leads to reap big on the same. There are two ways that one can use to obtain these leads; through lead generation or buying them. Although the two methods may be effective, you need to choose the best suited plan for you depending on urgency and their availability of you will be purchasing the same.
Melaleuca, Inc. is listed as a Direct Marketing Company. The company contracts with independent marketing executives who refer customers to Melaleuca that purchase its various lines of nutritional, pharmaceutical, personal care, household cleaning, and pet care products. They also offer travel, phone and credit card services. Customers receive discounts if they order a minimum monthly product supply, but are not required to maintain an inventory of products. The company states that it offers a "Satisfaction or Money Back Guarantee".
It was not until August 23, 2005 that the State Council promulgated rules that dealt specifically with direct sale operation- Administration of Direct Sales (entered into effect on 1 December 2005) and the Regulations for the Prohibition of chuanxiao (entered into effect on 1 November 2005). When direct selling is allowed, it will only be permitted under the most stringent requirements, in order to ensure the operations are not pyramid schemes, MLM, or fly-by-night operations.
It was not until August 23, 2005 that the State Council promulgated rules that dealt specifically with direct sale operation- Administration of Direct Sales (entered into effect on 1 December 2005) and the Regulations for the Prohibition of chuanxiao (entered into effect on 1 November 2005). When direct selling is allowed, it will only be permitted under the most stringent requirements, in order to ensure the operations are not pyramid schemes, MLM, or fly-by-night operations.
I see Melaleuca on here. I see that as both good and bad. They are an awesome company with a great compensation plan. However, they are not an MLM. They are not even listed with the federal agency that oversees those companies. They are a Consumer Direct Marketing company. How does that differ? While I am required to purchase a certain amount each month, that's all I need to purchase. It's all products I use in my own home for myself. I don't have a monthly quota to meet. I don't have to buy product and sell it to people. The idea is that the product goes to the consumer only. In fact, it's against company policy to buy product and sell it to others. The only comparison I see are the "levels" of customerS in my group. Can you shed any light on why you think they are an MLM? Thanks, so much!
infoUSA is the leading provider of sales and marketing support for products for all types of businesses, from small Mom & Pop shops to large corporations. The company compiles the world's finest databases of 14 million U.S. businesses and 200 million U.S. consumers, and 1.2 million Canadian businesses and 12 million Canadian consumers under one roof in Omaha, Nebraska.
If you are interested in learning more about the options of network marketing lead generation or would like to contract a company with specialty in your industry, give us a call at Farotech: 267-387-6620. Our marketing professionals are knowledge about all areas of the marketing process and can help you by developing an individualized business marketing plan to improve your sales and lead generation at this time.
If you are interested in learning more about the options of network marketing lead generation or would like to contract a company with specialty in your industry, give us a call at Farotech: 267-387-6620. Our marketing professionals are knowledge about all areas of the marketing process and can help you by developing an individualized business marketing plan to improve your sales and lead generation at this time.
I don't care where doTERRA in ranked. The oils are good, but the company SUCKS. It is all built on big bloggers. Don't have a big blog – you're going to make pennies while others demand you make a minimum $100 a month order. The company itself has great customer service, but try to reach compliance or tell them that your uplines are making fake accounts or ordering off multiple people in the downline just to ensure they make bonuses and NO ONE listens. It's supposedly geared to help the underdog succeed – this is a gimmick.
Appreciate the hard work studying this… Im apart of the #1 company on there Advocare… have been for 7 years and one of the higher paid single guys in the nation… I just have to disagree with "over priced Products" comment. There is a mark up on every product in the world… Our products actually work which is why those endorsers you mentioned turn down high level incomes with other companies to endorse us for a stipend of products per month. Advocare has numerous people making a great profit and even more just enjoying a product they would pay double what they do for to feel the way they do. Success rate isnt low my friend… Its just the quit rate is through the roof. Highly recommend everyone seeing this and you sir to watch "Rise of the Entrepreneur" by Eric Worre on Itunes to get some serious facts about the MLM industry. Thanks for all the research and blessings!
look if you go and search top MLM businesses, no matter what link you click on, the number one company is amway. Why everyone goes with different companies i don't get it, check it out compare to mary kay. Here's the thing though, I contract with amway, but my organization is worldwide. Mentorship organization. I feel which ever MLM business you choose, join a mentorship organization that is in that business. The reason why amway is number one is because of worldwide. it's only 10% of everyone that is in amway, yet 90% of the 6 and 7 figure earners are part of worldwide…why? because they broken down the company and know exactly how to succeed and retire quicker than someone who tries amway on their own or joins another mentorship company. what's the success rate? to those who do what others have done 100%. So at the end of the day, consider all of this. With amway and worldwide, it doesn't matter how old you are, where you come from, ANYONE can do it. Mary Kay is a female company, good luck getting a bunch of single dudes to make it with that.
With so many of the fastest growing MLM companies pushing to have you join, it can get confusing when you're looking at MLM products, compensation plans, where to get leads, marketing tips, and most of all – can I really make money with this? What you need to remember, is that the best MLM to join in your situation is going to come down to one thing – finding a product and a business you are excited about sharing!
Melinda F. Emerson, known to many as SmallBizLady is one of America's leading small business experts. As a seasoned entrepreneur, professional speaker, and small business coach, she develops audio, video and written content to fulfill her mission to end small business failure. As CEO of Quintessence Multimedia, Melinda educates entrepreneurs and Fortune 500 companies on subjects including small business start-up, business development and social media marketing. Forbes Magazine named her #1 woman for entrepreneurs to follow on Twitter. She hosts #SmallBizChat Wednesdays on Twitter 8-9pm ET for emerging entrepreneurs. She also publishes a resource blog http://www.succeedasyourownboss.com Melinda is also bestseller author of Become Your Own Boss in 12 months; A Month-by-Month Guide to a Business That Works. Her latest ebook, How To Become a Social Media Ninja; 101 Ways to Dominate Your Competition Online was released in 2012.
On the other hand, if you are the owner of the company where those 100 persons have offered their skills, time and talents, and if you can gain $1.00 from each person on the field, you will earn $3000 after 30 days doing nothing. Obviously, the time spent for both the worker and the owner are the same (30 days), but the gain on the side of the owner is tremendously huge.


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It's Open Improv, and it's a hell've lot more fun than whatever the hell else you were gonna do on a Tuesday.
Open Improv is one of the Sylvan's (VICELAND, Sketchfest, etc.) longest running shows. It started in a backyard with pizza and beer, and 8 years later we're running strong at our newest and best home, PianoFight. The first rule of Open Improv is %$#@ the rules, and the rest of the rules follow suit. It's a no-pressure- no-holds-barred comedy romp that proves the theory that anyone could be, and is, hilarious.
PianoFight's not just a theater, it's also a restaurant and bar!
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If you plan on dining, we recommend you arrive 1.5 hours early so you have plenty of time to eat before the show. Restaurant seating is first come first serve. Drinks are always allowed in the theaters.
Street parking is free after 6pm. We're located 2 blocks from Powell BART, numerous muni lines and there are 3 parking lots within 1 block.
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Datebook Tips
Sure, you can order food and drink at the indie arts venue, but if you aren't in the mood for polenta sticks or nacho tostadas, there are plenty of nearby eateries to choose from, like Esan Classic, which specializes in northeastern Thai cuisine or the mindful soul food at Farmer Brown. For a quick bite, Popsons is home to one of the best burgers in San Francisco. For boozier options, beer hall Mikkeller Bar and longtime gay dive bar Aunt Charlie's Lounge are neighborhood favorites.


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