Does surgical experience trump tumor biology (at least for patients at very high risk)?

We know from prior studies that recurrence of prostate cancer after a radical prostatectomy is related to tumor biology and to surgical surgical skill and experience, but is one more important than the other?

In a new analysis of their database of over 8,000 patients treated at three major prostate cancer centers, Vickers et al. have now investigated the association between biological predictors of progression (stage, Gleason grade and PSA level) and biochemical recurrence for subgroups of patients defined by the experience of their surgeon.

Their analysis included two separate cohorts: 6,091 patients treated by open radical prostatectomy (RP) and an independent replication set of 2,298 patients treated laparoscopically.

According to their analysis, in the patients treated with an open RP:

  • The likelihood (odds ratio, OR) of disease recurrence in patients with Gleason scores of ≥ 8 and advanced pathologic stage was dramatically lower when patients were treated exclusively by surgeons with higher levels of experience (i.e., only surgeons who had carried out 1,000+ prior cases).
    • For patients with Gleason scores ≥ 8: ORs were 5.6 when all levels of experience were included vs. 13.0 for patients treated by surgeons with 1000+ prior cases.
    • For patients with locally advanced disease (assumed to imply T3/4 disease): ORs were 6.6 overall vs. 12.2 for patients treated by surgeons with 1000+ prior cases.
  • The OR for disease recurrence did not increase dramatically when either patients had a Gleason score of 7 or based on patients’ PSA levels.

In the independent cohort of patients treated with laparoscopic surgery, predictiveness was lower overall (as one might expect because of the much lower numbers of patients) but the main findings from the open RP cohort were replicated.

To quote Vickers et al., “Surgery confounds biology.” The authors note that their findings “have no direct clinical implications,” but that future studies investigating biological variables as predictors of outcome after radical prostatectomy (and perhaps after surgical treatment for other forms of cancer too) should consider the impact of surgeon-specific factors.

When one looks at these data through the eyes of an individual patient, however, a clinical implication would seem to be apparent: patients with Gleason 8-10 disease or advanced clinical stage (cT3/4) were twice as likely not to have disease recurrence after surgery if they were treated by a surgeon with > 1,000 prior RPs under his or her belt.

It has to be noted, however, that this study is based on data from a very small number of such highly experienced surgeons, all currently believed to be working at two of the most highly respected prostate cancer clinical research centers in the world. It may well not be appropriate to generalize the result of this study beyond the centers and the surgeons involved. In particular, it may be worth recognizing that, at such centers, the most experienced surgeons are perhaps likely to focus their full attention more onto higher-risk patients, which may explain why there is less evidence of “surgery confounding biology” in the patients with “only” Gleason 7 disease or based on PSA levels.

What this study does suggest to The “New” Prostate Cancer InfoLink is that the higher your risk for progressive disease at diagnosis, the greater the care you should take to ensure that you find a highly experienced and skillful surgeon — if surgery is your treatment of choice. And we suspect that the same general rule applies to nearly every form of first-line treatment for prostate cancer.

5 Responses

  1. This article would benefit readers more if we knew who and where the surgeons were.

  2. Click on the link to the abstract and it will give you some very well-known names.

  3. Nothing trumps the cancer.

  4. Your last statement (“And we suspect …”), in particular, resonates. I think that the skill of brachytherapists and radiation therapists counts strongly too, in the same way as for surgeons. Considering, say, radiation therapy (photon or proton), it is not just a matter of an individual physician, but of physicists, technique, the whole experience and skill of a team that counts. This factor makes comparisons of treatment methods difficult.

  5. This is a ridiculous study! Now you need to do at least 1,000 of these operations to be good at treating high-grade disease? What is supposed to happen during the operation that it takes 1,000 cases to get it right? The full study is not available [on line] but what does disease recurrence mean? Is it a rise in PSA, which is still a poor predictor of survival, or was it time to metastases? Did the patients have a local recurrence which might be related to surgical technique or was it a combination of local and distant disease? The worst thing that could happen is to tell patients that based on this report they need to find a surgeon who has done at least 1,000 RPs for them to get good treatment.

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