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Medical Forum / Diseases and Disorders / Prostate Cancer / February 2005Better Surgical Outcomes Documented?
A little help here? Can any of you give me citations of studies that show that surgical outcome in PCa is linked to the skill/experience of the surgeon, and that care in a facility that has more surgeries is correlated to better outcomes? By the way, I am doing fine six months after surgery. Have had only one major continence problem in that time, and potency ahead of the curve also.  SignatureAge 46 PSA: 1.4 (12/00), 2.0 (7/02), 10.3 (3/2/04), 6.0 (retest 3/18/04) Biopsy 4/5/04 cancer in 10% of one core Gleason 6 (3+3); clinical stage T1c Bone Scan negative; pre-surgery PSA 2.8 RRP 7/27/2004 Pathological stage T2a, Gleason 6 (3+3) ³Tumor confined to prostate" and "Surgical margins free of tumor² Glenn, glad to hear you are doing well. No citations, or at least no detailed citations, but it is a recurring theme in Dr. Walsh's book "Surviving Prostate Cancer." Admittedly, the good doctor described himself, or his perception of himself, in the book as the epitome of the skilled/experienced doctor. But, then, you said "outcomes" and I'm perceiving you mean all outcomes. Walsh's focus re skill and experience is more on impotence. If you are talking cutting out the cancer, getting all of it, not dropping any back into the hole, etc., etc., then skill and experience only stand to reason. SignatureProstate Cancer Survivor (so far), not a doctor PSA 16 10/17/2000 @ 46 Biopsy 11/01/2000 G7 (3+4), T2c RRP 12/15/2000 G7 (3+4), T3bN0M0 Seminal Vesicle involvement, Neg margins PSA .1 .1 .1 .27 .37 .75 EBRT 05-07/2002 @ 47 PSA .34 .22 .15 .21 .32 Lupron (1 mo) 07/21/2003 @ 48 PSA .07 .05 .06 Lupron (4 mo) 8/03 (48), 12/03, 4/04 (49), 09/04 (50) non Illegitimi carborundum > A little help here? Can any of you give me citations of studies that show > that surgical outcome in PCa is linked to the skill/experience of the [quoted text clipped - 3 lines] > By the way, I am doing fine six months after surgery. Have had only one > major continence problem in that time, and potency ahead of the curve also. Glenn Enoch asked...snip... > Can any of you give me citations of studies that show > that surgical outcome in PCa is linked to the skill/experience of the > surgeon, and that care in a facility that has more surgeries is correlated > to better outcomes Glenn...These references make the point that volume counts Variations among individual surgeons in the rate of positive surgical margins in radical prostatectomy specimens; J Urol. 2003 Dec;170(6 Pt 1):2292-5; Eastham JA, Kattan MW, Riedel E, Begg CB, Wheeler TM, Gerigk C, Gonen M, Reuter V, Scardino PT CONCLUSIONS: While the clinical and pathological features of cancer are associated with the risk of a positive margin in radical prostatectomy specimens, the technique used by individual surgeons is also a factor. Lower rates of positive surgical margins for high volume surgeons suggest that experience and careful attention to surgical details, adjusted for the characteristics of the cancer being treated, can decrease positive surgical margin rates and improve cancer control with radical prostatectomy. A SYSTEMATIC REVIEW AND CRITIQUE OF THE LITERATURE RELATING HOSPITAL OR SURGEON VOLUME TO HEALTH OUTCOMES FOR 3 UROLOGICAL CANCER PROCEDURES; J Urol. 2004 Dec;172(6, Part 1 of 2):2145-2152; Nuttall M, van der Meulen J, Phillips N, Sharpin C, Gillatt D, McIntosh G, Emberton M. CONCLUSIONS:: Outcomes after radical prostatectomy and cystectomy are on average likely to be better if these procedures are performed by and at high volume providers. For radical nephrectomy the evidence is unclear. The impact of volume based policies (increasing volume to improve outcomes) depends on the extent to which "practice makes perfect" explains the observed results. Further studies should explicitly address selective referral and confounding as alternative explanations. Longitudinal studies should be performed to evaluate the impact of volume based policies. However, I seem to recall a study (can't find it) that compared two high-volume surgeons at the same institution and found they had markedly different positive margin rates. The conclusion was that high-volume alone is not a sufficient condition to increase the chances for success (sounds logical). Here are two more references that make the point that local institutions can perform on the same level as university hospitals: Radical Prostatectomy in a Community Practice; The Journal of Urology 167 (2002) 224-228; Jeffrey H. Cohn and Rizk El-Galley Long-term outcomes after radical prostatectomy performed in a community-based health maintenance organization; Cancer. 2004 Jan 15;100(2):300; Zhang Y, Glass A, Bennett N, Oyama KA, Gehan E, Gelmann EP. ...Best wishes and good health, Ron Ron, I have been looking at 2 surgeons that perform robotic LRP only at their respective hospitals. One doc has done about 200 procedures and the other over 1000.They had similar results as far negative margins--91% vs 94%. As far as continency(no pads at 6 months) the numbers were also similar--90% vs 96%. At 6 months return of potency(intercourse) was 66% vs 66% for men under 6o y.o.. The more experienced physician published that 82% had sexual function(not necessarily intercourse) at 6 months. The only thing that varied much was the surgical time(4 hours vs 2 1/2 hours) and the fact that one doc does 2 surgeries/day and the other does 6. Does this mean that one surgeon is quicker because he is more experienced or is the other doctor more thorough? Possibility they have different procedures? There might be a tendency to pick the more experienced surgeon, but is this always the best choice? > Ron, I have been looking at 2 surgeons that perform robotic LRP only at > their respective hospitals. One doc has done about 200 procedures and the > other over 1000. The one with 1000 is a lot more experienced > They had similar results as far negative margins--91% vs > 94%. As far as continency(no pads at 6 months) the numbers were also [quoted text clipped - 3 lines] > only thing that varied much was the surgical time(4 hours vs 2 1/2 hours) > and the fact that one doc does 2 surgeries/day and the other does 6. 6 surgeries a day! I wouldn't want to be #6 > Does > this mean that one surgeon is quicker because he is more experienced or is > the other doctor more thorough? Possibility they have different > procedures? There might be a tendency to pick the more experienced > surgeon, but is this always the best choice? Stanley...Good question. Unfortuneately, experienced, high-volume surgeons can do it the "wrong" way every time. I'm data driven and a doctor's recurrence statistics count for a lot with me. As you know such data does not exist for robotic RP. If you are in shape to begin with and have no significant morbidities, than studies suggest RRP and open RP have similar side effect recovery times...Best wishes and good health, Ron >Subject: Re: Better Surgical Outcomes Documented? >From: "yelnats" black@EMAILPROTECTED [quoted text clipped - 5 lines] >other over 1000.They had similar results as far negative margins--91% vs >94%. Margins is not dependent on the surgeon- you have negative margins if you caught it early enough. Continency may depend on avoiding cutting away too much more of the bladder wall than is needed. Potency depends on how much damage is done to the two nerve bundles, and whether the nerve bundles were free of cancer and could be left in place- which again depends on how soon you detected the cancer rather than on the skill of the surgeon. How long you go without rising PSA is the true test. >As far as continency(no pads at 6 months) the numbers were also >similar--90% vs 96%. At 6 months return of potency(intercourse) was 66% vs [quoted text clipped - 6 lines] >procedures? There might be a tendency to pick the more experienced >surgeon, but is this always the best choice? Danny McCarty wrote...snip... > Margins is not dependent on the surgeon- you have negative margins if you > caught it early enough. Hi Danny...I'd debate this point with you. Margin status is a function of surgeon skill. It may also be a function of other variables as well. Robotic RP provides a good example of the skill variable. Surgeons early on the learning curve have a higher positive margin rate than those that have done several hundred surgeries, even after populations are normalized...Best wishes and good health, Ron >Subject: Re: Better Surgical Outcomes Documented? >From: "ron" oitbso@yahoo.com >Date: 2/8/2005 5:47 PM Central Standard Time >Message-id: <1107906477.906482.172450@g14g2000cwa.googlegroups.com> Ah, yes- but there is a difference between "capsule penetration" and "seeing capsule penetration"- I referred to the former. For the poor surgeon, it's there but he didn't see it. >Danny McCarty wrote...snip... >> Margins is not dependent on the surgeon- you have negative margins if [quoted text clipped - 7 lines] >than those that have done several hundred surgeries, even after >populations are normalized...Best wishes and good health, Ron Danny...Now I'm confused. We started talking about margin status and now you've mentioned capsular penetration. These are two different things. The surgeon can influence margin status, but not capsular penetration...Best wishes and good health, Ron I vote with Danny. As long as the surgeon removes the prostate and its capsule, which presumes a certain skill level, a surgical margin is positive if that excised capsule has cancer cells on its surface. A positive margin is a positive margin whether the doc uses a scalpel or a cherry bomb to excise the prostate; it's just easier to DETERMINE the margins with the scalpel. If the excised meat has cancer cells on its surface, they try to remove more meat. If that still has cancer on its outer surface, they take a bit of bone of a thin layer of rectum. If THAT still has cancer cells on its surface, it's time for some SERIOUS real time decisions (about bags) and adjuvant therapy. At least that's what I've read. I. P. > Danny McCarty wrote...snip... > > Margins is not dependent on the surgeon- you have negative margins if [quoted text clipped - 7 lines] > than those that have done several hundred surgeries, even after > populations are normalized If the surgeon slices through the tumor with his scalpel, then there is a positive margin. If tumor exists on the surface of the prostate in an area that was not surgically treated, then you have extraprostatic extension or extracapsular extension. When I speak of a surface, I'm implying that this area was not a contiguous part of other tissue, hence there is no excision or cutting on this surface...Ron Glenn, Glad to hear about your outcome. If you don't mind my asking, since I am also 46 and had my surgery 12 days before you had yours (with similar results), I was just curious about what your view of potency being ahead of the curve is? Incontinence disappeared after 6 weeks, but usable erectiosn aren't quite there yet... |
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