Archive for Op-Ed/Inside Scoop
I want to pass on some information that newly diagnosed men absolutely should consider. It is from the excellent blog “Palpable Prostate” by A. Black. The gist of this is that for intermediate- and higher-grade PC pts (GL 7+, PSA 10+), *open* surgery for PC is considered preferable to laparascopic (which includes robotic) surgery by a number of notable surgeons. One reason is that it allows for more extensive dissection of the lymph nodes, which is very important in this situation.
I am NOT saying that if you are in an intermediate or high-risk category you should not have minimally invasive RP. What I am strongly suggesting is that you consult at least one open (traditional) surgeon to get a different point of view. Do some research and find the most qualified doctor in your area. Don’t settle for just anybody.
Dr. Alan Partin (of the famous “Partin Tables”), head of Urology at Johns Hopkins (top-rated urology faculty and top-ranked hospital in US by usnews.com), will not do a laparascopic RP on any patient with a Gleason grade over 7. This is also what I was told by Dr. Bertrand Guilloneau when I called about making an appointmentt for my husband a few years ago. Dr. Guilloneau pioneered the use of laparoscopic RP in France and was practicing it long before it was approved in the U.S. He is also head of minimally invasive PC surgery at Sloan-Kettering, the #2-ranked cancer hospital in the US . (I understand that Dr. G. has since changed the rules, but I’m not sure why.)
The website I referred to, Palpable Prostate, has a 4-part survey of the relative merits ot the different kinds of PC surgery. http://palpable-prostate.blogspot.com/2007/03/rp-vs-lrp-vs-rlrp-part-1-open-surgery.html. Then there is a wrap-up of “what surgeons and others say”. The information here is comprehensive and well-sourced, with links to all cited references. Here is a pertinent excerpt of doctors’ opinions:
Dr. Kevin Slawin of Baylor College of Medicine:
“Dr. Slawin recommends that [patients with] Gleason 6 and less extensive Gleason 7 [3 + 4] can have laparascopic surgery, while patients with more extensive Gleason 7 [4+3] disease and Gleason 8-10 patients have open surgery and are most effectively treated when a careful, extended lymph node dissection, that includes the removal of all lymph nodes situated in the iliac, hypogastric, and obturator regions, is performed as part of the prostatectomy procedure. This type of lymph node dissection can only be best performed using an open, rather than robotic-assisted, approach.”
“Patients with larger Gleason 7 – 10 tumors, situated primarily at the base of the prostate, who have a high risk of seminal vesicle invasion, can achieve a lower positive margin rate and higher cure rates than those with similar tumors treated with standard techniques, either open or robotic, when treated with “en bloc” resection of the prostate, SVs and bladder neck.”
David F. Penson
“An Evidence-Based Analysis (Feb 7, 2007) concludes that for low risk patients (all of: GS 6, PSA < 10, cT1 or cT2a) either open or robotic is reasonable, but for high risk patients (any one of: GS 8 or higher, PSA > 10, cT2b or higher) open surgery is preferred. For intermediate risk patients (GS 7) the proper approach is unclear.”
BTW, the results achieved of by minimally invasive surgeons (such as short recovery time), can often be equalled by an experienced open surgeon. Also, there is no evidence that the rate of ED is lower in patients who’ve had laparascopic PC surgery. Finally, I believe there are fewer urinary problems with open surgerey.
In any case, read the information for yourself. Always remember that the most important thing in choosing a treatment is saving your life, i.e., *cancer control*.
I am including an excerpt from a blog post written by Dr. Michael Glode, an experienced genitourinary oncologist. I highly recommend his site because what you get from Dr. Glode is straight talk.
Dr. Glode writes that he’s had reservations about robotic prostate surgery for a long time. He acknowledges that it is now seen by urologists as the way of the future, but he questions whether it is really superior to old-fashioned open surgery. Dr. Glode doesn’t believe it is. His points out that robotic surgery is just a different method for achieving the same result. He also alludes to a recent New York Times article which found that patients who’ve had robotic surgery express more regrets than those who’ve had the old-fashioned kind:
“Now a new article has appeared which confirms all the same things. Unrealistic hopes for outcomes that simply aren’t any better in any study lead to more disappointment among patients. I wish it wasn’t the case, but I told you so…. Sometimes technology leads to terrific advances. At other times, it is simply a new way of doing the same old thing with different tools. You can use a hand wrench or an air powered wrench to tighten the lug nuts on your car’s wheels. Either way the wheel should stay on if done correctly. It won’t stay on any better with one versus the other. BUT…a great mechanic using either one might notice that nail in the tire that hasn’t yet caused a flat tire.”
I think Dr. Glode has a point.
I really hate to criticize robotic surgery. I have always tried to focus on the positive. And people squeal when you even question this “sacred cow.” Naturally, patients want to think they got superior treatment, and most recent PC surgery patients have had robotic surgery.
I think it’s important to point out the deficits of robotic surgery because some doctors (and patients) make this treatment out to be the holy grail, which it isn’t. The problem is that if you believe you have found the holy grail, *you will stop looking for it*. We can’t afford to do that.
The truth is that robotic surgery still leaves a significant number of men with incontinency and impotency problems, among others. This is true even with nerve-sparing. And the oncological outcomes (success in getting rid of the cancer) are worse with robotic surgery than with with the old-fashioned kind (see my post, “Mayo Clinic”, etc.) *unless the robotic RP is done by a member of a small coterie of very, very experienced surgeons — think 500-1,000 surgeries.
What would represent a true miracle in the (surgical) treatment of prostate cancer would be a therapy that *improves cancer outcomes without causing side effects that significantly impact quality of life in a negative way.* Unfortunately, robotic surgery is not the answer. And we will only get better therapies if we fight for them.
There was an article in the New York Times recently which stated that men who’ve had robotic vs. open prostatectomy express more regrets. I don’t think this is because robotic is a worse treatment, but that it is often presented to patients in an unrealistic, overly optimistic way. For example, I recently read the published results for robotic PC surgery by a prominent surgeon, and he stated that the potency rate for his post-surgical RP patients was “up to 97%”. Not sure what that even means, but I can tell you those stratospheric results are unrealistic.
Finally, there’s a problem with the skill of many (probably the majority) of the surgeons who are performing robotic RP. This method of surgery has grown astronomically in recent years, as was recently reported on the cover of Barron’s magazine in an article about the rise of Intuitive Surgical Co., maker of the da Vinci robot. The article pointed out that most surgeons who perform robotic surgery are ”late adaptors”, which is a fancy way of saying they only acquired the machinery recently. The article also stated that the vast majority of surgeons who perform robotic RP’s do very few of them on a regular basis. Apparently, the “learning curve” for robotic surgery is very, very steep, and the bad news for patients is that most robotic surgeons aren’t there yet.
There is an article in today’s New York Times in which the author describes his thought processes as he went about first choosing a treatment and then a doctor after he was diagnosed with PC. Trouble is the guy is a newbie who doesn’t know anything but thinks he does . But didn’t we all?? I think this article is important to read because I see so many SMART men (and women) making the exact same (bad) choices. Here are some excerpts from the article, along with my comments.
In Prostate Cancer, Pick a Number, Any Number
By Burt Solomon, August 25, 2008
“I was counseled to pooh-pooh the higher-than-desirable Gleason score of 6, derived by adding the aggressiveness in every spot of cancer, because there was so little cancer in each.”
Get the facts straight. A Gleason score is NOT “derived by adding the aggressiveness in every spot of cancer“. Fair warning of what’s to come.
“I was only dimly aware of the evidence that most prostate cancers never become dangerous, even if left alone. But because nobody can tell which ones will and which ones won’t, the information was useless to me.”
Don’t make decisions when you’re “dimly aware”. And the information we have, although not precise, is not quite useless. You should have checked out all treatments before making a decision, including active surveillance.
“I quickly decided to have surgery to remove the prostate, but I had to choose between the two types”.
You should never decide “quickly” to have surgery. Buy now, pay later.
“I cared most about my plumbing returning to normal. But this was when the numbers really began to confuse things.”
Big mistake! Your first priority should be getting rid of the cancer. The plumbing comes in a distant second.
“One option was to go to Johns Hopkins in Baltimore, my hometown, where the older-style, slash-and-scoop surgery was devised. But the doctors there, my urologist said, cherry-picked their patients — no fatties need apply — to minimize the complications in getting the plumbing up and running again.”
Yes, they devised “slash and scoop” but also nerve-sparing surgery. And why talk trash about an excellent hospital because of what one doctor said? Presumably sugeons who “cherry-pick” patients, i.e., choose the ones with potentially the most favorable outcomes in order to skew their results, do so to lower their rate of positive margins (a sign that they likely got the cancer out), rather than to ”get the plumbing up and running again” ASAP.
“The other choice, called robotics, was newer and cooler. But the procedure has statistical distortions of its own. Some robotics surgeons have been known to exaggerate the speed of recovery by removing the catheter too early.”
Surgeons yanking catheters prematurely? I never heard of that. My husband had his cath in for three weeks!
“So both sides were skewing the numbers to market themselves.”
A bit pretentious for a newbie.“
A college classmate, a physician with a low opinion of his profession, advised me to forget the numbers, to visit both surgeons, look them in the eye and decide which one I liked. Huh? Why should I care? I wasn’t drinking a beer with the guy. Partly, my friend said, a likable surgeon would respond if something went wrong; an arrogant one might not admit a mistake. And partly, well, my friend really couldn’t articulate it, but he felt certain.”
Look what happened to our country because we elected a president we wanted to have a beer with. Hiring a not-so-good doctor based on personality is the easiest trap to fall into! Empathy can be faked, but not competence. And remember, personality and character are not the same thing.
“Likable” and “surgeon” don’t ordinarily cohabit a sentence,
( (What about Dr. Miles, Dr. Eastham, et al.)
but when my wife and I met with the robotics surgeon, we loved him. Patient, personable and the furthest thing from arrogant, he told us how his technique had improved from his first 200 operations to his second 200. (I was No. 431.) Only twice, he said, in Nos. 4 and 17, had the robotics failed and he had proceeded to the more intrusive surgery. His percentage of complications, he added, was as low as at Hopkins. I canceled my appointment in Baltimore.”
“We loved him”.
Remember, love is blind, so when you go see the doctor, check your hormones at a the door. Do you want a good doctor or the Dale Carnegie of the medical profession? By all means, if you find a doctor you click with, keep him/her in mind but don’t blow off the rest of your appointments (like we did). And it’s always a good idea to consult with at least a few surgeons.
Also, you can’t believe everything a person says just because he has an M.D. after his name. Ask for proof. And in terms of experience, 430 is a lot but there are surgeons around who’ve done thousands.
“The surgery wasn’t bad at all, and my recovery was startlingly swift. Eight days afterward, I returned to have the catheter removed — none too early — and to learn if the cancer had spread. When I asked the surgeon if the pathology report was “positive” — meaning good news — he winced.
“The news was good: The cancer had not spread beyond the prostate. But 35 percent of my prostate had turned out to be cancerous, considerably more than a dusting. I had dodged a bullet; the numbers had lied again.”
Too soon to celebrate. Hasn’t even had his first PSA test!
I initially posted my previous message about depression and PC treatment on a site I have been frequenting which brings together people from diverse backgrounds. You might be interested to read the responses I got, which came from a broad spectrum of the PC community: patients and their partners, a surgeon, psychiatrist, psychologist, a number of patient advocates and (indirectly) a nurse and sex therapist who works with PC patients.
After carefully reviewing the feedback that my post generated, I came up with a list of suggestions on ways that doctors can improve the lives of their PC patients. I’m going to share it with you, even though it’s impromptu and unedited.
How to Improve Life for Prostate Cancer Patients and their Partners
* The primary treater, e.g., surgeon, should refer the patient for “penile rehab” with a *highly competent ED specialist* at 2 months after RP. MSK automatically schedules men for a follow-up with their resident “sexpert”, Dr. Mulhall, at six weeks. There is some evidence that penile rehab might actually have a prophylactic effect for long-term ED. More important perhaps, ED therapy, usually with injections, can allow a man to have an erection again and feel better about himself, and the couple to resume sexual relations. Giving the patient a script for Viagra that you just keep renewing can be very costly to the patient, since if it doesn’t work in the beginning it probably won’t work for many months, if at all. Don’t throw out the pt’s money.
* Be honest with patients. Don’t promise them the moon and quote statistics that have no basis in reality. You are just setting your pts up for a fall. Be up-front about ALL potential side effects of treatment and their likelihood of occurring. Advise the patient of all interventions that can help. The risk is that the patient may walk out of the room, but it’s their life and their choice. As someone pointed out, ethically the patient should be told of *all* treatment options, even via written materials, and left to decide. Ultimately, patients prefer doctors who are honest with them and hate the ones who leave them most unprepared for adverse events, i.e., “blindsided”. For instance, my husb’s surgeon said that he was a textbook case for recovery and estimated his chances of getting ED at about 10% with nerve sparing. Afterwords, he told us both nerves had been spared when in fact only one had. We were not expecting ED so it came at us like a meteorite. It took us a very long time to even recognize that there was a problem.
* Provide the patient with a list of support groups in the area and online as well as other sources of help (e.g., telephone helplines, cancer organizations). One man wrote in a PC forum the other day that he was about to kill himself when he discovered the online PC community. That’s what saved him.
* Monitor the pt’s psychological state at follow-up visits, particularly in the case of younger patients. If you suspect depression, recommend that they seek help from a mental health prof’l. Many men have been helped with psychotropic medications, psychotherapy, group support, relationship counseling and encouragement of “spiritual” pursuits.
* Provide high-quality, candid written materials to pts on how PC treatment might affect them, in particular their sexuality and relationships with partners. Provide resources for treatment.
* Encourage patients to engage in religious or spiritual pursuits or other activities that give meaning and pleasure to their lives. A good social life is the best buffer against depression, so encourage patients to maintain close ties with family and friends. My husband, e.g., has spent much more time with his family since his PC diagnosis and it has been a boon to both.
* We should do more research on the problems of PC patients and partners. Find out which interventions have the most promise and try to implement them.
* Enlist the help of a variety of medical professionals including nurses, social workers and GPs, as is done in places like the UK. Follow their model of a “holistic”, team approach.
* Be especially sensitive to the needs and vulnerabilities of younger patients.
* For patients who have undergone ADT, be up-front about side effects and encourage relationship counseling. One study showed that as many as 50% of couples who’ve undergone this treatment are basically living together only because they don’t want to bother with divorce.
* Take a genuine interest in the patient before, during and AFTER treatment. Don’t cut ‘n run. Surgery, e.g., is a PROCESS, and the doctor needs to do proper follow-up and be available to the patient.
* Rule out physical causes of depression that can result from the cancer or treatment.
* Global changes have to be made to our healthcare system to allow doctors to spend more time with patients. We should try to turn out more GPs — they’re the first line of defense against illness. Revise our insurance system so that people who change or lose coverage don’t have to bounce from one GP to another. Best thing for your health is a GP who knows and cares about you.
* Help newly diagnosed patients navigate the maze of PC treatments by establishing a multi-disciplanary model for treatment. Patients should meet first with an oncologist, then consult with prof’ls in various fields, e.g., surgery, radiation, etc. They should be given accurate, specific information and then left to make up their own minds. NCCN practice guidelines are a good model. If the doctor can’t spend that much time with the pt, they can provide written info for the pt to review.
* If a pt experiences a loss of libido after treatment, help them understand the cause and recommend possible treatments.
* Mention online PC support forums like prostate pointers.org’s excellent PC and Intimacy list (PCAI), which now has a “wiki”, a sort of reference library for readers. Also for ladies, there is prostate-help.org’s “Ladies Only” forum.
* Explain to partners of men with PC how they can help. They are often clueless. Phoenix5.org has some good articles for companions, one of which is “10 Pointers for Women”. http://phoenix5.org/companions/10Pointers.html. This article, written by a man, describes the physiological,emotional and sexual changes that often follow PC treatment and advises women how to be most helpful and supportive.
* Be nice to your patients. Care for them and they will care for you.
One more thing: Replace the textbook, “Torquemada on Treatming Prostate Cancer” with something a little more modern. : – ))