Are clinical benefits of RALP being over-hyped to unsuspecting prostate cancer patients?

Back in March, a group of authors from three major medical centers published a report in the Journal for Healthcare Quality strongly suggesting that U.S. hospitals were inappropriately over-promoting the  use of robot-assisted surgery for treatment of prostate cancer.

This was hardly the first time that anyone had suggested that the supposed benefits of robot-assisted laparoscopic prostatectomy (RALP) for treatment of localized prostate cancer were being “over-hyped.” However, Jin et al. were able to offer data to support their opinions. According to their analysis of the web sites of 400 randomly selected U.S. hospitals in June of 2010:

  • 41 percent of hospital web sites described robotic surgery.
  • 37 percent of the hospitals presented information about RALP on their homepage.
  • 73 percent of the institutions used manufacturer-provided stock images or text.
  • 33 percent of the hospital web sites offered direct links to a manufacturer’s web site.
  • 86 percent of the hospital web sites made statement about the “clinical superiority” of RALP.
  • 32 percent of the hospital web sites described improved cancer control being associated with RALP (as compared to other forms of surgery).
  • Not one of the hospital web sites mentioned risks associated with RALP.

The authors’ basic conclusion was the information being provided by hospitals regarding the use of RALP over-estimated its benefits, largely ignored relevant risks, and was being strongly influenced by the manufacturer. Additional information was made available in a media release from Johns Hopkins.

Now a new article in Cancer, by Neuner et al. (and an associated commentary on the Medscape Oncology web site) have provided data suggesting that the acquisition of a da Vinci robot by a hospital has been associated with a significant increase in the use of RALP — beyond what would have been expected based on historic therapeutic need.

Neuner et al. set out to determine whether hospital acquisition of robotic technology was associated with volume of prostate cancer surgery. To do this they used the inpatient dataset of claims records from 2002 to 2008 and the acquisition dates of robotic technology to study the rates of prostatectomy in Wisconsin hospitals. In analyses that accounted for hospital and referral region characteristics, changes in the numbers of radical prostatectomies at specific hospitals were studied along with the dates of acquisition of the robotic technology acquisition. The analyses were carefully designed to take account of hospital and referral region characteristics.

Here are the key study findings:

  • 10,021 prostatectomies were performed in 52 hospitals in Wisconsin’s 8 health referral regions during the study period.
  • The average (mean) prostatectomy volume in hospitals that did not acquire the technology, by quarter, was 4.5 in 2002 and 3.1 in 2007-08 (a reduction of 31 percent).
  • The mean prostatectomy volume in hospitals that did acquire robotic technology, by quarter, was 16.5 in 2002 and 24.8 in 2007-08 (an increase of 51 percent).
  • The acquisition of a robot was associated with a 114 percent annual increase (range, 62 to 177 percent) in hospital prostatectomy volume.
  • The average Wisconsin hospital prostatectomy volume was unchanged during 2002 through 2006 but increased by 25.6 percent in 2007.

The authors conclude that acquisition of robotic technology occurred rapidly in Wisconsin hospitals, and that hospitals that acquired a robot had large increases in prostatectomy volume.

Now let us be very clear that there absolutely are some benefits to the use of RALP as compared to open surgery for treatment of localized prostate cancer. These are primarily those of less blood loss during surgery, a shorter hospital stay, faster post-surgical recovery, and less need for post-surgical pain management. It should also be noted that these benefits actually have nothing to do with the use of the da Vinci robot; they are also found through the use of standard forms of non-robot-assisted laparoscopic radical prostatectomy (LRP). However, there are absolutely no data whatsoever to suggest that RALP is “better” or “safer” that open surgery or LRP in terms of such outcomes as excision of the cancer, the risk for positive surgical margins, post-surgical continence, or recovery of erectile function.

The da Vinci robot is a technologically sophisticated surgical tool. Once a surgeon has learned to take advantage of its capabilities (which may require as many as 250 or more procedures), it certainly facilitates the surgical conduct of a high-quality radical prostatectomy for some surgeons — but that is not the same as improving surgical outcomes. The “New” Prostate Cancer InfoLink has little doubt that hospitals have been inappropriately promoting the benefits of RALP as compared to other forms of treatment for prostate cancer, and we further suspect that this inappropriate promotion has led to many men having RALP as a treatment for their prostate cancer that may have been either unnecessary or inappropriate because they had unrealistic expectations about the outcome of their treatment by this method. The quality of outcome after radical prostatectomy has little to do with the technology being used and everything to do with the skill, expertise, and focus of the individual surgeon who does the operation.

The other thing that there is no doubt about is that the hospitals have profited from being able to charge more for this procedure because of the Byzantine nature of health care cost reimbursement in the USA.

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