Archive for Choosing a Doctor
IT’S NOT THE TECHNIQUE, STUPID, IT’S THE SURGEON — *OR IS IT?*
Posted by: | CommentsNOTE: I ADDED INFORMATION TO THIS STORY AFTER I INITIALLY PUBLISHED IT. PLEASE CONSIDER THIS NEW INFORMATIONIT CAREFULLY.
The Wall Street Journal Health Blog entry today (Surgery for Prostate Cancer: Comparing Different Techniques, by Jacob Goldstein) concerns the results of a study recently reported in the Journal of the American Medical Association which compared the results of traditional, open radical prostatectomy (RP) with the newer minimally-invasive techniques such as laparascopic RP (LRP) and robotically assisted RP (RALP).
http://jama.ama-assn.org/cgi/content/short/302/14/1557?home
The new study did not address the comparative rates of “oncological efficacy” (i.e. cancer control), as determined by the rates of positive post-surgical margins in the two groups. But previous studies have found that cancer control is *worse* in patients who have minimally invasive RP, *unless the surgery is performed by an exceptionally skilled laparascopic surgeon* — part of an elite clique who have at least 500 surgeries under their belt (no pun intended). Obviously, for a cancer patient, NOTHING is more important than the actual results of his surgery, regardless of the technique used.
CORRECTION: The study found that cancer control was the same in both groups.
With regard to side effects, the study found that minimally invasive surgery resulted in shorter hospital stays and fewer transfusions. But the researchers also found that patients who underwent LRP or RALP had a higher incidence of incontinence and impotence than those who had open surgery. I was aware of previous findings of more “urinary bother” in men who had had minimally invasive RP, but this study went *even further* by adding the ED results to the picture.
[ADDED]
The disparity in reported side effects of genitourinary problems, incontinence and impotence was dramatic: only 2% of traditional RP patients reported persistent side effects versus 5% of MIRP patients.
The researchers stressed that the men who had minimally invasive surgery tended to be of a higher socio-economic class, so perhaps the increased rate of reported side effects had something to do with higher expectations, or maybe it’s that people who are better off complain more.
[ADDED]
Interestingly, there were differences in outcomes based on geographical areas and ethnic groups. In spite of the fact that black men were far less likely than whites or Asians to have minimally invasive surgery, the struggling city of Detroit was at or near the top of the list. My guess is this is because a famous minimally invasive prostate cancer surgeon practices in the Motor City, and the patients are mostly “medical tourists”.
The ultimate meaning of this is that, if RP is in your future, ALWAYS CHOOSE THE MOST EXPERIENCED SURGEON YOU HAVE ACCESS TO, ONE WHO HAS HIGH LEVELS OF PATIENT SATISFACTION, REGARDLESS OF TECHNIQUE. THAT’S HOW YOU WILL ACHIEVE THE BEST RESULT. As Dr. Arnon Krongrad, a well-regarded laparascopic RP surgeon who also founded the New Prostate Cancer Infolink (www.prostatecancerinfolink.net) wrote in this blog, “Find your Tiger Woods and don’t micromanage the clubs.” So if the most experienced surgeon in your area happens to use the open technique, do not despair — in the hands of a competent surgeon it’s not the barbaric picture that some partisans portray it to be. A day or two extra at the hospital, at most.
[ADDED]
BASED ON NEW INFORMATION, I RECOMMEND RECONSIDERING MINIMALLY INVASIVE RP UNTIL MORE OR BETTER INFORMATION BECOMES AVAILABLE.
I know it’s hard to absorb the concept that the newest technology is not necessarily the best one for you. But as the authors of the above study put it, the adoption of the high-tech, minimally invasive approach to RP may just “be a reflection of a society and health care system enamored with new technology that . . . had yet to uniformly realize marketed or potential benefits during early adoption.”
To read the complete story from the WSJ blog, cut and paste the following URL:
http://blogs.wsj.com/health/2009/10/13/surgery-for-prostate-cancer-comparing-different-techniques/
Why You MUST Go to An Expert to Have Laparoscopic Prostatectomy
Posted by: | CommentsI must say I found the following article in USA Today ( 4/1/09, by Liz Szabo) , bonechilling. A British study confirms what I’ve said many times: that when it comes to performing minimally-invasive radical prostatectomy or laparoscopy (which includes robotically assisted surgery, *although that was not the subject of this study*), NO amount of experience on the part of the surgeon is enough.
And there is another very important point being made which I have NOT heard before: That “open” surgeons (those who perform the traditional radical retropubic prostatectomy) who later switch to laparascopic surgery produce (much) worse results than doctors who initially specialize in this area.
Here are some excerpts from the USA Today article (more comments at end):
“Prostate cancer patients whose surgeons have anything less than the highest degree of experience with a popular new procedure may be at greater risk of relapse, according to a study in The Lancet Oncology April 1 edition.
<snip> “While it takes at least 250 surgeries for a doctor to become proficient at the traditional surgery — allowing patients to feel confident that doctors removed all of the cancerous tissue — surgeons need to do at least 750 keyhole procedures to become proficient. Doctors who are used to performing traditional surgery actually have a harder time learning keyhole techniques than novice surgeons who are learning to perform the procedure for the first time, the study shows.
“That suggests that doctors shouldn’t try to switch back and forth between techniques, but instead focus on perfecting their skills on just one type of prostate removal and patients who opt for keyhole surgery should go to cancer centers where doctors specialize in the procedure, authors say.”
The take-home message for men who have decided on laparascopic prostatectomy but do not live near a top-rated urologic oncology facility (“Center of Excellence) is that they should consider traveling to one or finding a “high-volume” surgeon in private practice. (For some guidance about top hospitals, look at usnews.com, “Rankings”, keyword “Cancer”, not Urology”. Also, at castleconnolly.com, “America’s Top Doctors for Cancer”.) A lot of people are unaware that there are charities which make arrangements for patients and their families to stay close to the hospital for the duration of treatment. I know because I was on the receiving end of such a favor. Ask the hospital social worker or chaplain about this.
How to Find a Good Doctor
Posted by: | CommentsI would like to share with you some general tips for finding/researching doctors which I have accumulated in the last two years based on my experiences with my husband’s illness. (Note that resources vary from state to state.)
*Ama-assn.org — basic info about doctors
*Castle Connolly’s “America’s Best Doctors for Cancer”. Second edition came out recently. The best thing since sliced bread. Lists 2,000 docs in 16 sub-specialties. Go to castleconnolly.com or you can find it in the library.
* Also check out “America’s Top Doctors” (castleconnolly.com, local editions avail. for NY and Chicago.)
* There is also checkbook.org, website of Consumer’s Union, a nonprofit group which publishes books of recommended doctors and hospitals.
** Sometimes local newspapers will publish doctor reviews. (Here, NY Mag. does a yearly feature on this. Search “best doctors” and your area). I have found this method to be extremely helpful. I just used it to find docs in Columbus, OH and Kansas City.
* Try to find a doctor who is associated with a good teaching
hospital.
* Check local PC advocacy orgs. You might want to ask if they know any docs.
* Check your state’s Health Department (state.gov), specifically its division of Professional Licensing, to find out about the doctor’s status, malpractice history, etc. Often the listing will offer you a doctor profile (see below).
* State Physician Profile. Provides extensive info about a particular doctor. This is mandated by law in certain states, such as NY.
** Hospital — critical decision. Don’t just go to the nearest one.
Be wary of small community hospitals. *Look at the US News
(usnews.com) or other hospital rankings. Try to go to a center of
excellence for Urology (or if you have PC, cancer) even if it means travelling somewhere. You can go to usnews.com and look up the details. Don’t rely on your general impression of a hospital. One may be good for one thing and bad for another. Example: MSK and NY Presb are both first-rate hospitals in NYC. However, MSK is rated #1 in the country for the treatment of cancer; NY Presb is #24.
** Convenience should not be too high on your list of priorities. Your goal is getting the best treatment for the illness you have.
** With PC: Don’t fixate on any single option such as robotic surgery (which seems to be robotically prescribed for everybody, regardless of the situation). Do not rule out open surgery or any other treatment before you have found out more about it. Research the pros and cons carefully.
*You might want to consult a medical oncologist for a different viewpoint (e.g., radiation, hormone therapy). Urologists
mostly recommend surgery
** Go see the best general-purpose urologist in your area, somebody who has absolutely no use for you. By that I mean he/she doesn’t need your money, to practice on you, to accumulate another statistic or to add another surgery to the list. A person with many years of experience and an established reputation. Such a doctor is more likely to give you the truth. If you can, go see several. If you have to pay out-of-pocket it’s worth it if you can afford it.
* Don’t just go to the people your doctor refers you to. They are probably his golfing buddies.
* Go to prostate-help.org and read the chapter for the “Newly
Diagnosed.” Pay special attn to the part about selecting docs. It’s like boot camp, but it’s worth it.
* For general info about a doctor you can do a basic google search. Personal details can make a difference. Once I chose a gyn because he was listed online as giving a lot of money to a particular charity (was a tie-breaker).
*For info about a doctor’s scholarly output, try googlescholar.com.
* Many people here admire Dr. Stephen Strum for his long-time
dedication to the PC community, even though some of his ideas are not mainstream. I would go to pcri.org and have a look at Dr. Strum’s list of recommended doctors.
* Read Scardino’s “Prostate Book”. Also Strum’s “Primer on Prostate Cancer”, the most detailed book ever written about this subject (but keep in mind the caveat above). Both are available on Amazon.
* For excellent, objective info on PC, go to endotext.org. This site has comprehensive info for practicing doctors but it is also
understandable to laypeople. Has won awards for quality of content and clarity.
*Ask for recommendations from people in online forums such as this (I belong to 10 PC ones) and from people you know.
*If you have a general practitioner you trust absolutely, ask him or her for some names.
*For patient referrals, search the archives of PC groups for accumulated wisdom.