Archive for Newly Diagnosed
NOTE: 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).
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.
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.
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.
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:
I 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.
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*.