The Monday news update: March 2, 2009

New reports today address:

  • Positive surgical margins: RALP vs. RRP
  • Circulating tumor cells levels and survival of castration-resistant prostate cancer patients
  • Patient preference and management of post-surgical incontinence

There have been significant questions about whether patient quality of outcome is sacrificed during early learning of the relatively new techniques of robot-assisted laparoscopic prostatectomy (RALP). White et al. have responded to at least one of these questions. The authors compared the incidence of positive surgical margins obtained using RALP, during the initiation of a robotics program, with that from a similarly matched cohort of open radical retropubic prostatectomy (RRP) cases as performed by a single surgeon. Between December 2005 and March 2008, 63 patients underwent RRP and another 50 underwent RALP by a single urologist. The authors compared the incidence of positive surgical margins and the location of positive margins among the 50 RALP patients and 50/63 matched RRP patients. They also evaluated the preoperative PSA level, preoperative Gleason score, clinical stage, postoperative Gleason score, tumor volume, and pathologic stage for each patient. The positive margin rate for the RRP group was 36 percent compared with 22 percent for the RALP group (P = 0.007). The incidence of positive margins for pathologic stage pT2c disease in the RALP group was 22.8 percent compared with 42.8 percent in the RRP group (P = 0.006). In addition, fewer positive margins were found in the Gleason 7 RALP patients than in the Gleason 7 RRP patients (29 vs 60 percent, P = 0.003). The authors note in conclusion that significantly lower positive margin rates can be achieved in RALP patients as compared to RRP patients, even during the learning period. The “New” Prostate Cancer InfoLink wishes to emphasize that while this study cannot be used to demonstrate that any other surgeon actually achieved similar results, it can be used to demonstrate what must theoretically be possible for any other surgeon.

Scher et al. have published data from an initial attempt to assess the value of circulating tumour cell (CTC) count as a prognostic factor for survival in patients with progressive, metastatic, castration-resistant prostate cancer receiving first-line chemotherapy. These data were also presented at the Genitourinary Cancer Symposium last Thursday. Their data suggest that, at 4, 8, and 12 weeks after treatment, changes in CTC number are strongly associated with risk for progression, whereas changes in PSA titer are weakly or not associated (p>0.04). The authors conclude that, “CTC number, analysed as a continuous variable, can be used to monitor disease status and might be useful as an intermediate endpoint of survival in clinical trials.” However, they carefully go on to state that, “Prospective recording of CTC number as an intermediate endpoint of survival in randomized clinical trials” will be necessary to confirm these preliminary data.

Kumar et al. have published an interesting article on patient choice with respect to the management of post-prostatectomy incontinence. There are basically two types of treatment now available for the management of post-surgical incontinence in prostate cancer patients. Implantation of an artificial sphincter is the “gold standard” treatment, but this is a mechanical device. The more recent development is the so-called “male sling.” In the case of the sling, early outcomes have been promising in select patients, but long-term data are not yet available. The authors reviewed data from 133 men with post-prostatectomy incontinence who underwent an initial procedure to correct incontinence. A total of 84 male sling (63 percent) and 49 artificial urinary sphincter (37 percent) procedures were performed. The surgeon recommendation was an artificial urinary sphincter in 63 men (47 percent) and a male sling in 46 (35 percent). A total of 24 men (18 percent) were given the option of either procedure. All patients who were advised to receive a male sling chose it. When an artificial urinary sphincter was recommended, 75 percent of patients chose it, while 25 percent chose a male sling. When given a choice, 92 percent of patients chose a male sling and only 8 percent chose an artificial urinary sphincter. It appears that, while most patients adhered to their surgeon’s recommendation, men offered the choice of an artificial urinary sphincter vs a male sling are willing to go against the surgeon recommendation for an artificial urinary sphincter in order to avoid the mechanical natire of the artificial sphincter, despite the lack of long-term data. The “New” Prostate cancer InfoLink would emphasize that the male sling may not be appropriate for men who have more severe forms of post-surgical incontinence, and the choice of the sling may only be appropriate for some incontinent patients.

4 Responses

  1. The story comparing positive margins for RRP vs. RALP does not accord with other credible research that has been done on this subject. So it doesn’t surprise me that the research was done at the Michigan State University College of Osteopathic Medicine, Wyoming, Michigan. Not exactly MD Anderson.

    That a laparoscopic surgeon “initiating” an RALP program at a hospital would have a far superior track record than an experienced open surgeon doesn’t pass the smell test. Sorry. We know RALP takes a long time to master.

  2. I just read the entire abstract and am even more convinced of the implausibility of the study results. It compared the outcomes of ONE open surgeon vs. those of participants in a newly initiated RALP program. With such a wide disparity in results, the only explanation I can think of is that the surgeon in question was blind.

    Should I really believe that there was a 31% disparity between results obtained by a trainee in RALP vs. a (presumably) experienced open surgeon for GS 7 disease?

    I’d like to see these results replicated at a respectable institution.

  3. Dear Leah: I must respectfully disagree with you. This study reports the results achieved by a single surgeon who did all of the procedures referred to in a single time period. The abstract very clearly states this, as follows: “We present our series comparing a single urologist’s positive margin rates during the learning curve of a robotics program with his experience of a similarly matched cohort of RRP patients.” And with respect to the institution the surgeon was working at, who cares, if he is a good surgeon?

  4. All this really demonstrates is that, for the urological surgeon involved, he has had better margin results than he did with RRP. Judging from his exceptionally high percentage of positive margins in RRP, I would suggest that he may not be very good at that procedure. This allows for a substantial improvement when only compared to his own RRP capabilities. Several other studies have found exactly the opposite results.

    I have long held that RALP likely improves the abilities of somesurgeons, just as Dr. Krongrad feels LRP improved his individual results are superior to RRP, as he said, “in his hands”. His own statement indicated that RRP, “in his hands,” “nearly always” required transfusions averaging 2 pints of blood. Although he stated in an article published in a Florida newspaper, he stated that his preferred LRP method would have saved 7,000 pints of blood, based on the erroneous assumption that each of 3,500 RRPs cited would have required comparable transfusion numbers that HE had experienced.

    Statistically, modern RRPs reported in more current studies in the U.S. generally report transfusions as necessary in a substantial minority of surgeries performed. My own surgeon at Mayo Clinic reports that his own results show such a necessity in rare instances (substantially under 10%).

    There is little doubt that if I was to have Dr. Krongrad do my surgery, I would want him to do LRP, but if I was to have Dr. Walsh (Johns Hopkins) or Dr. Catalona (Northwestern), both of whom have publicly stated they feel RRP is a superior technique (in their hands), then that is what I would want them to perform.

    I tell those whom I counsel about prostate cancer, that there are two ways to approach treatment choice. One is to choose the procedure you wish to have performed and then find the “best” physician who regularly performs it, to provide the treatment. The second, is to choose the physician you prefer and have the treatment which he feels most comfortable in performing and feels most appropriate to your individual circumstances. Which method you prefer depends on many factors, including your own personality characteristics. What treatment you have and who you have
    perform it, also depends on numerous factors, including economics, psychological and physical limitations and personal priorities.

    Such decisions should be informed ones, and can and should, only be made by the patient after he feels he has acquired the necessary information to make it one. Once made, it should be approached with confidence and should never second-guessed, regardless of results, since no one can ever know what the result of any other choice would have been.

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