Annual volume of radical prostatectomies in US doubled between 2003 and 2009

In order to initially gain or maintain board certification, American urologists must (among other things) submit case logs to the American Board of Urology. A new study, published recently in the Journal of Urology, has used data from these case logs to assess current trends regarding the use of robot-assisted laparoscopic and open radical prostatectomy.

It appears that the real use of robot-assisted laparoscopic prostatectomy (RALP) is indeed growing … but not necessarily in quite the way described in claims made by industry.

Lowrance et al. report data from an analysis of the case logs of 4,709 American (non-pediatric) urologists who submitted such logs for initial board certification or re-certification between 2004 and 2010. It is important to understand, in assessing these data that:

  • The operative case logs must cover all cases for a consecutive 6-month period during the 17-month period prior to the due date.
  • Re-certification of Board-certified urologists is required at 10 and 20 years after initial certification.
  • Urologists initially certified prior to 1985 are not required to submit case logs as part of their re-certification process.

Thus, the case logs from 2004 to 2010 only encompass data from a subset of all currently Board-certified, non-pediatric urologists.

It is also important to understand that, for the purpose of this study, non-robot-assisted forms of laparoscopic radical prostatectomy were included with the robot-assisted group.

Here are the core findings of the study:

  • 3,374/4,709 urologists submitted case logs that included at least 1 case of radical prostatectomy.
  • 2,413/3,374 urologists (72 percent) reported performing open radical prostatectomy only.
  • 961/3,374 urologists (28 percent) reported performing at least 1 case of RALP.
    • of these 961 urologists, 308/3,374 (9 percent) reported performing RALP only.
  • Among patients receiving a radical prostatectomy reported in 2003 by urologists certified or re-certified in 2004, only 8 percent were treated with RALP.
  • Among patients receiving a radical prostatectomy reported in 2009 by urologists certified or re-certified in 2010, 67 percent were treated with RALP.
  • The average (median) age at time of re-certification of urologists who exclusively performed only open radical prostatectomy was 43 years.
  • The average (median) age at time of re-certification of urologists who performed only RALP or both RALP and open radical prostatectomy was 41 years.

These findings further suggest the following:

  • A 737 percent increase in the use of RALP between 2003 and 2009.
  • That 67 percent of all radical prostatectomies conducted in 2009 were carried out by RALP (as opposed to the 80-90 percent that has previously been reported from industry sources).

The most surprising statistic associated with this study, however, is that, between 2003 and 2009, the total number of radical prostatectomies being carried out by any means appears to have almost doubled — from 6,188 among the 427 urologists re-certified in 2004 to 11,290 among the 500 urologists re-certified in 2010. The extent to which this finding is wholly associated with the uptake of RALP is clearly impossible to determine. However, this increase in volume of radical prostatectomies occurred despite a full awareness of the potential risks associated with the over-diagnosis and over-treatment of low-risk prostate cancer, and the increase does seem to have been concentrated among those surgeons who performed RALP as opposed to open surgery.

5 Responses

  1. Shameful!

  2. Sitemaster:

    Does the original article interpret the data as saying that prostatectomies increased over this time period? This would be hard to determine from these data, in part because those initially certified prior to 1985, who apparently do not require re-certification, would be a larger percentage of urologists in 2003 than in 2009. In addition, if the robot has led to different age patterns of urologists doing prostatectomies, this could affect time trends in the reported volume of prostatectomies in this sample.

    In any event, a little poking into data at the National Center for Health Statistics does not at first glance seem consistent with a doubling of prostatectomies. They report 158,000 prostatectomies in 2009.

    I’m not sure if the data are completely comparable, but the 2003 National Hospital Discharge Report available from NCHS appears to report 167,000 prostatectomies in 2003.

    Of course, this says nothing about the rate of surgical procedures to newly diagnosed men.

    In addition, it occurs to me that there might be time trends in the percentage of urologists who renew board certification. To what extent is it by regulation or practice required that a urologist renew their Board certification to keep on doing prostatectomies? Some time trends here could also affect trends in the study cited in the original post.

  3. Dear Tim:

    (1) Yes, this highly experienced group of authors does indeed state very clearly that the number of radical prostatectomies appears to have doubled over the time period. The data above are taken directly from the full text of the paper.

    (2) In looking at the NCHS data (e.g., for 2009), you need to appreciate that those data include all types of prostatectomy (i.e., transurethral resections of the prostate [TURPs] as well as radical prostatectomies and a small number of other much less common procedures). They are therefore in no way comparable to the data being reported in the paper referred to above.

    (3) The authors are very careful to point out a number of provisos about the accuracy of their data in the full text. However, they are very clear that there appears to have been a major increase in the overall number of radical prostatectomies over the time period referenced.

    (4) You don’t have to be a certified urologist to carry out a radical prostatectomy. Any competent surgeon can do this if he or she wants to. However, I don’t think anyone would argue about the idea that the vast majority of RPs carried out in America each year are in fact being done by Board-certified urologists.

    (5) In the full text of the paper, the authors state that “approximately 90,000 RPs are done annually in the United States.” They give no specific reference for this statement, so I have to assume that this is now a widely accepted number within the urology community. I can remember that, as recently as 2008, the generally accepted number was only about 75,000 per year, so it is clear that there has been a considerable increase in the numbers of these procedures.

    If you want details, you will need to take it up with Dr. Lowrance (who, I am sure, would be happy to provide you with a PDF of the full paper). I would note, however, that three of the authors (Drs. Eastham, Stephenson, and Scardino) are highly respected specialists in the management of prostate cancer who would be most unlikely to put their names to a paper like this unless they were very confident of the statements being made, and another two (Drs. Savage and Maschino) are members of the Department of Epidemiology and Biostatistics at Memorial Sloan-Kettering Cancer Center.

  4. I read this article with sadness and resignation. The research is pretty solid, and wholly available, that indicates that while laparoscopic and robotic innovations improve short-term outcomes such as surgical bleeding and surgical pain, these techniques provide NO meaningful improvement in long-term outcomes related to controlling cancer and minimizing the very, very common side effects of incontinence and sexual dysfunction.

    Professionally, I study, teach, and conduct policy analysis about demographic trends. Personally, I have spent a great deal of time the past few years trying to protect my husband from over-diagnosis and over-treatment of prostate cancer. Where do these two issues intersect?

    Most of the folks who make it to the point of becoming surgical urologists (and radiologists) are pretty bright. Regardless of what their own field’s research indicates about the relative indolence and potential for conservative management of many prostate cancers, as a field they’ve just about made it to the demographic motherlode market of baby boomers.

    Today, the prostate cancer treatment community is barely on the opening cusp of a 30- to 40-year period of having literally millions of cases of prostate “cancer” to diagnose and provide treatment to in the health care marketplace, the for-profit marketplace — at least in the US. No doubt the pharma corporations selling all the after-treatment potions and props needed to help men simulate normal functionality after current treatment impacts are in no big hurry to differentiate between low-risk and high-risk prostate cancer. They’ve invested mightily in men being incontinent and impotent. They need a market to serve.

    Shifting gears in clinical and business practices to screening protocols that minimize over-diagnosis and adopting active surveillance and/or investing in retraining and new equipment to perform focal therapy most certainly represents a diminution in potential profit-taking of removing lots and lots and lots of prostates with the current skill set and tools such as da Vinci robots that they’ve just about got paid off (and as an equal opportunity critic, I should acknowledge the PBRT and CyberKnife machines those radiologists so love).

    I’m very, very worried that the general resistance to active surveillance and more refined analysis of biopsy results (i.e., going back to biopsy grading at lower levels than 3 + 3) has a great deal more to do with the potential for profitability of treating this huge demographic bulge in the manner most profitable today than it has to do with what current science and clinical practice tells us about how to keep men from dying of prostate cancer.

    And I want to be clear: I don’t think that individual clinicians and researchers sit around, rubbing their palms together Snidely Whiplash style, contemplating ways to trick men into being over-treated so they can make more moulah. Over-diagnosis and over-treatment of prostate cancer are just manifestations of a structural flaw produced by the very (VERY) unfortunate confluence of allopathic medicine and for-profit health care. It’s a zeitgeist problem, an error in this era’s cultural understanding of health and disease, not an individual character flaw.

    Is there light at the end of the tunnel? Well, there were enough “out of the closet” clinicians and researchers to fill two-days worth of panels at an active surveillance conference in December, 2011, though sadly, many speakers felt the need for caveats and genuflection to the status quo. And, ironically, the mentality of “rationing” of health care to manage overall costs — while applied to a kicking and screaming market of patients who perceive it as a loss — will likely save many millions of men from being unnecessarily severely damaged. But as Lowrance et al. make very clear, it’s going to be very, very hard for both clinicians and patients to let go of the cultural meme of the take-no-prisoners, no-loss-is-too-great battle against the Big C.

  5. Dear Tracy:

    I think you have hit the nail on the head. This is also not a problem exclusive to prostate cancer by any manner of means. Breast cancer, as just one example, suffers from almost exactly the same set of medico-cultural phenomena.

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