(At least in Ontario) it’s not about where you have your surgery

Over the years, data have clearly shown that where a patient has surgical treatment for localized prostate cancer has little impact on short- and long-term outcomes (although who carries out the surgery very definitely does).

A recent paper by Lawrenschuk et al. has now shown that, in the Canadian province of Ontario, the occurrence of positive surgical margins (PSMs) after radical prostatectomy in 2005 and 2006 was not significantly different at major teaching institutions or high-volume hospitals as compared to community hospitals or low-volume institutions.

On behalf of Cancer Care Ontario, the authors carried out a careful audit of pathology reports to determine the province-wide rate of PSMs among men with pathological stage T2 after radical prostatectomy for localized prostate cancer. An experienced cancer pathology coding specialist extracted the PSMs data from eligible pathology reports. Only those reports that provided a pathological stage were included in the analysis.

The results reported by the authors are as follows:

  • Analysis was based on a sample of 728 consecutive reports over a period of 2 months in 2005 and 1,346 consecutive reports from 2006.
  • Data were available from 43 hospitals in which the volume of radical prostatectomies ranged from 12 to 625 cases.
  • The average (median) surgical volume was higher in the teaching hospitals (median, 194 procedures) than in the community hospitals (median, 121 procedures)
  • The average (median), province-wide rate of  PSMs for men with pT2 disease was 33 percent (range, 0 to 100 percent).
  • Teaching hospitals had a 26 percent rate of PSMs compared to a rate of 34 percent at community institutions.
  • There was no statistically significant correlation between surgical volume and rate of PSMs.
  • Average (mean) rates of PSMs were not significantly different between community institutions and teaching institutions.
The authors draw three conclusions from their research:
  • The Ontario-wide rate of PSMs among men with pT2 disease after surgery for localized prostate cancer is higher than those published from  recognized centers of excellence.
  • Within Ontario, rates of PSMs from larger volume centers were not significantly better than the rates from lower volume centers (which contradicts previously published data).
  • These data may be explicable in terms of such factors as the skill levels of individual surgeons, patient selection, pathological processing, and interpretation of the pathological data.

The “New” Prostate Cancer InfoLink is increasingly concerned that, given data of this type, it is critically important for patients to be able to identify which surgeons have the greatest ability to reproducibly produce outcomes of the highest quality when executing radical prostatectomies. However, such data are not available to the “consumer.” Given the increasing availability of independent quality analysis data on many other forms of consumer-directed product and service, it is increasingly apparent how the lack of such data on the abilities of individual surgeons (and other physicians) may be seriously impacting the ability of patients to select high-quality care with confidence (and not just for the treatment of localized prostate cancer).

5 Responses

  1. The data are surprising. However, one key fact is in line with what we would expect: “Teaching hospitals had a 26 percent rate of PSMs compared to a rate of 34 percent at community institutions.” When you think about it, 26/34 equates to 76%, of a 24% reduction in the rate of margins at teaching versus community hospitals. As a patient, I find that highly significant.

  2. I do not understand the meaning of the term “positive surgical margins”. Does that mean too much tissue was removed?

  3. Dear Jim:

    A “positive surgical margin” occurs when the surgeon cuts so close to the cancer in the prostate that cancer is evident on the surface of the surgical specimen removed. This implies that there may have been significant cancerous tissue left behind in the patient after surgery.

    A different way to think about this is that in fact too little prostate tissue was removed (rather than too much).

    One reason for positive surgical margins is when the surgeon, in seeking to carry out a so-called “nerve-sparing” procedure to allow recovery of erectile function, over-compromises in the other direction and does not cut far enough outside of the prostate capsule to effectively remove all of the cancer.

    Not all positive surgical margins necessarily result in subsequent disease progression … but positive surgical margins do increase the risk for disease progression post-surgery.

  4. A new study might be required because some local hospitals are presently having difficulty trying to control C. difficile. This study makes no mention of hospital-acqired infections, which seems to have increased since 2005-06 when this study was done. In 2011 I would be hesitant to have an elective prostate biopsy when there is an increased risk of being injected with antibiotic resistant bacteria.

  5. C. difficile infections appear to have been a significant problem in Canadian hospitals and in the community for a number of years now. No one seems to have any really good idea exactly why. It seems hard to believe that this is something specific to Canada. It may well be that for some reason Canadian hospitals have been better at looking for (and therefore finding) this particular type of hospital-acquired infection in recent years after some outbreaks in 2000-05.

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