A “changing of the guard” in prostate cancer research?

For nearly 30 years, since shortly after the introduction of the so-called “nerve-sparing” radical prostatectomy by Patrick Walsh of Johns Hopkins in 1982, there has been general lack of willing in the urology community to publicly question any aspect of the value of surgery as the gold standard for the treatment of localized prostate cancer. However, …

Starting with the increased acceptance of the long-understood idea that some form of expectant management (active surveillance, watchful waiting, call it what you will) might be a sound choice for carefully selected patients with low- and perhaps intermediate-risk disease, the wisdom of placing radical prostate cancer surgery on a pedestal has increasingly seemed to come into question. From a “urologic acceptance” point of view, one might date this to the publication of an editorial by Peter Carroll, MD in the Journal of Urology (“Early stage prostate cancer — do we have a problem with over-detection, overtreatment or both?”) in April 2005, although it has to be said that some members of the urology community had been asking these questions for decades.

In the past week we have seen the publication of two papers that can only be described as newly “transformative” in their perspectives.

In the first paper, Savage and Vickers called into question whether even 20 percent of the urology community are actually capable of executing a radical prostatectomy with sufficient skill to provide a reliable, high-quality patient outcome. In the second paper, Reynolds et al. showed that absolute (leak-free and pad-free) continence levels after radical prostatectomy at a major and respected academic medical center occurred in only about 33 percent of all patients who were completely continent prior to their radical prostatectomy.

For any reader who has been monitoring the prostate cancer literature for most of the past 20 years, these two papers represent a “radical” new mindset within at least a part of the urologic oncology community. Not only are the authors willing to raise subjects which would have been taboo little more than 5 years or so ago; in addition, their academic mentors are willing to help them do so, and respected urology journals are willing to publish these data.

Medicine is a conservative “science” — and for good reason, but a downside of that conservatism has always been a tendency to “stick with the herd” and not question the wisdom handed down by the academic leadership of the community — or at least, not in public. Then, every so often, comes a minor (or even a major) revolution. Dr. Walsh himself caused such a revolution when he carried out the first “nerve-sparing” radical prostatectomy. Guillonneau , Krongrad, and Vallancien caused another when they started to carry out laparoscopic radical prostatectomies in France and then in America on a regular basis.

But the incipient revolution we are seeing today is much deeper. It is a revolution in which younger members of the academic medical community have started to say that the prostate cancer clinical research community needs to hold itself to higher standards, and to publish data that are less about the successful aspects of specific techniques and are focused more on an honest assessment of the measurable pros and cons of those techniques.

The “New” Prostate Cancer InfoLink welcomes this new, forthright attitude to prostate cancer research. Above all else, it is in the best interests of patients, because it will make it easier for the newly diagnosed to acquire accurate information about the potential quality and outcomes of the medical and surgical care they may need. Ideally, over time, it will also lead to better comparative data on the different techniques available to treat men with localized and more advanced forms of this disease.

One Response

  1. These “green leaves” of change are indeed welcome. Maybe the processionary caterpillar analogy will no longer apply at some time in the future?

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