THE “NEW” PROSTATE CANCER INFOLINK

A report by Hu et al. in the most recent issue of the Journal of Clinical Oncology has provided further evidence to substantiate a recurring theme of this web site: that outcomes to specific treatments for early stage disease are highly dependent on the skill and experience of the treating team and not the specific technique. In this case the candidate for study was minimally invasive radical (laparoscopic) prostatectomy (LRP).

The database used for this study covers the period 2003 to 2005, so it is clear that the vast majority of surgeons using LRP at that time were still early in their learning curves. It is therefore unsurprising that, compared to open radical retropubic or perineal prostatectomies, the outcomes were less good in the long term (albeit better in the short term).

It should be clearly stated that (in the opinion of The “New” Prostate Cancer InfoLink) the authors begin with a false premise: that “Demand for minimally invasive radical prostatectomy … to treat prostate cancer is increasing.” We would suggest that demand for LRP has actually been driven by the way it has been marketed to hospitals and surgeons and presented to patients by the urologic surgery community. For example, we would be amazed to hear that many patients had been told that,

I’d like to use this new technique on you. You’ll recover faster. You’ll have less post-surgical pain. You’ll be at less risk for a blood transfusion during the surgery. On the other hand, you’ll only be my [insert number of choice]th patient, so I’m not sure that the outcome in the long term will be as good as if I do the operation using an open procedure.

The authors assessed utilization, complications, lengths of stay, and salvage therapy rates for LRP versus open radical prostatectomy in order to determine whether LRP surgeon volume is associated with better outcomes. They identified 2,702 men undergoing either LRP or open radical prostatectomy between 2003 and 2005 using a 5 percent sample of national Medicare beneficiaries. They also sought to assess the association between surgical approach and outcomes, adjusting for surgeon volume, age, race, comorbidity, and geographic region.

The results demonstrated that, in this sample of Medicare beneficiaries, utilization of LRP increased from 12.2 percent in 2003 to 31.4 percent in 2005. Men undergoing LRP versus open radical prostatectomy had fewer perioperative complications (29.8 vs. 36.4 percent) and shorter lengths of hospital stay (1.4 v 4.4 days); however, they were more likely to need and receive salvage therapy (27.8 v 9.1 percent). The results also demonstrated that patients of surgeons who had a high volume of LRP experience had  fewer anastomotic strictures and less salvage therapy.

Unsurprisingly, the authors conclude that men in this sample undergoing LRP versus open radical prostatectomy “have a lower risk for perioperative complications and shorter lengths of stay, but are at higher risk for salvage therapy and anastomotic strictures. However, risk for these unfavorable outcomes decreases” with increasing surgical experience and volume of LRP patients.

The “New” Prostate Cancer InfoLink wishes to emphasize that the key learning from this paper is not necessarily that LRP is less effective in the long term than open forms of surgery. To the contrary, the key learning for patients is that they should be sure to understand, prior to surgery, exactly how many procedures their surgeon has done using the technique he or she proposes and what his or her personal results are to date. Other studies have shown that it takes about 250 procedures to reach a high level of repeatable skill for any form of radical prostatectomy (regardless of how many procedures he or she may have done with another form of prostatectomy).