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Variation in prostate cancer control even among experienced urologic surgeons

Posted Jan 26 2010 12:00am

It has long been known that patient outcomes and complications after prostate surgery vary among surgeons to a greater extent than may be accounted for by chance.

In an article to be published shortly in the Journal of Urology, Bianco et al. have now reported that such so-called “heterogeneity” is also evident even among experienced, high volume surgeons. In other words, which of two experienced, high volume surgeons that a patient gets treated by may impact his long-term outcome post-surgery.

The authors studied data from 7,725 patients with clinically localized prostate cancer treated by a total of 54 surgeons at 4 major American academic medical centers between 1987 and 2003. Biochemical recurrence was defined as a serum PSA level ≥ 0.4 ng/ml, followed by a higher level. The core results of this study were as follows:

  • There was statistically significant heterogeneity in the prostate cancer recurrence rate that was independent of surgeon experience (p = 0.002).
  • 7 experienced, high volume surgeons had an adjusted 5-year prostate cancer recurrence rate < 10 percent
  • 5 experienced, high volume surgeons had an adjusted 5-year recurrence rate rate > 25 percent.
  • Significant heterogeneity was still evident after the authors made appropriate allowances for possible differences in patient follow-up, patient selection, and stage migration.

The authors conclude that a patient’s risk of recurrence after radical prostatectomy may differ depending on which of 2 surgeons the patient sees and gets treated by – even if the surgeons have similar experience levels.

Now we should be clear that The “New” Prostate Cancer InfoLink is far from surprised by the results of this study. We are all aware that there is a big difference between a competent surgeon who does a lot of procedures and “one of the very best.” This is as true for surgeons as it is for sculptors or artists. Most professional artists are not Rembrant or Picasso!

As the authors point out in the full text of their article, a key question here is how the gap can be narrowed between “the very best” and those who are highly experienced but not quite as good technically — and that’s if you accept the premise that surgical skill and technique really are the underlying cause of the heterogeneity (which will be disputed by some).

From a patient point of view, however, there is a simple lesson here. “Good” may not be good enough, and “experienced” does not necessarily correlate to “highly skilled” or “one of the best.” Of the 7,725 patients in this study, 853 were treated at the Cleveland Clinic, 4,168 at Memorial Sloan-Kettering Cancer Center, and 1,704 at Wayne State University Harper University Hospital, which are three highly reputable prostate cancer centers. But exactly who carried out the operation seems to have made a very real difference.

The range of outcomes in this study is perhaps the most serious issue. The “very best” experienced surgeon in this study had a 99 percent probability of biochemical recurrence-free survival among his/her patients. The “least good” experienced surgeon could offer his patients only a 73 percent probability of biochemical recurrence-free survival. That’s a 26 percent variance in outcome!

The bottom line, to quote Bianco et al., is that “Heterogeneity in medical outcomes is undesirable and suggests that some patients experience a less than optimal outcome.” Deep down, the urology community has known that such heterogeneity has existed for years. The “New” Prostate Cancer InfoLink congratulates the authors for finally providing concrete evidence of such heterogeneity. We hope that this will rapidly lead to insistence on superior training, greater skill levels, and greater patient focus among those physicians who wish to make a career out of prostate cancer surgery. A greater focus on active surveillance as first-line management for low risk patients, combined with a real focus on high quality in surgical and radiotherapeutic procedures when they are necessary might massively impact the “harms” all too commonly associated with the active treatment of localized prostate cancer.

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