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Medical Forum / Diseases and Disorders / Prostate Cancer / April 2006RRP experience matters
When I had a RRP almost two years ago, I did not go with the suburban urologist who diagnosed my PCa, but instead went to a well-known Urological Surgeon at UCLA who had done many RRPs. This was based on Medline research that predicted better outcomes with more experienced surgeons. The statistical study below validates this approach. Surgeon Experience Affects Outcomes Following Prostatectomy Better outcomes are seen after prostatectomies performed by more experienced surgeons MONDAY, Mar. 6 (CancerConsultants.com) -- According to results recently presented at the 2006 Prostate Cancer Symposium in San Francisco, patients with prostate cancer have improved results when their prostatectomy is performed by surgeons who have performed a larger number of prostatectomies compared to surgeons who have performed fewer such procedures. Results from some clinical studies have indicated that surgeons who are experienced in specific surgical procedures may provide their patients with better outcomes than surgeons who are less experienced in the procedure. Researchers from Memorial Sloan-Kettering Cancer Center conducted a clinical trial to evaluate outcomes of prostatectomies and surgeon experience with the procedure. This study included 7,849 men with early prostate cancer who underwent a prostatectomy between 1987 and 2003 at one of the following four cancer centers: Cleveland Clinic, Wayne State University, Baylor College of Medicine, or Memorial Sloan-Kettering Cancer Center. None of the patients had received chemotherapy, hormone therapy, or radiation therapy prior to surgery. This study included 74 surgeons. Patients had better outcomes if their prostatectomy was performed by a surgeon experienced in the procedure: * At 5 years, progression-free survival was 88% for patients whose surgeons had performed 250 or more prostatectomies. * At 5 years, progression-free survival was 79% for patients whose surgeons had done only 10 prostatectomies. * The rate of patients experiencing a rise in prostate-specific antigen (PSA) levels following surgery increased significantly among patients whose surgeons had performed fewer prostatectomies. The researchers concluded that patients who undergo a prostatectomy by a surgeon who has performed a greater number of these procedures have improved outcomes compared to patients whose surgeon has performed fewer procedures. They stated that surgeons who performed 250 or more prostatectomies produced the best outcomes. Men with early prostate cancer who are considering a prostatectomy may wish to ask their physician who will be referring them to a surgeon or their surgeon about the number of prostatectomies he or she has performed. Reference: Bianco, FJ, et al. Outcomes Measurement Influence of the Surgeon on Cancer Control After Radical Prostatectomy. Proceedings from the 2006 Prostate Cancer Symposium. Abstract 272. -- produced by CancerConsultants.com Copyright ©2005 CancerConsultants.com. All Rights Reserved. Agreed. I was dx'd by a fairly young uro. Although I thought that he was an excellent doctor, I was not impressed by his surgical experience. I eventually went with a PC surgeon at the Cleveland Clinic with over 1000+ open and over 300+ laparoscopic/robotic procedures under his belt. Also, I remember reading in Newsweek some months back that the RLRP, robotic procedure, is 14% more likely to be successful in cancer control after RP than the conventional open method. But who knows. It was the right choice for me after doing my research. My point? Go with experience, and in my opinion, use advanced technology in the right hands. Hopefully I was right in my decision. B.A. There are a couple of other published studies that support this position, e.g. "high-volume" surgeons perform better than their "low-volume" counterparts. I've attached the abstract of a study that analyzes the "high-volume" aspect from a different perspective. "High-volume" does not guarantee that the surgeon has good technique; some "high-volume" surgeons make the same mistake(s) in every surgery they perform and poor outcomes are the result. Looking at a surgeon's record of outcomes is probably more important than looking at the number of surgeries he or she has performed...Ron J Urol. 2005 Jun;173(6):2099-103 Variations among high volume surgeons in the rate of complications after radical prostatectomy: further evidence that technique matters. Bianco FJ Jr, Riedel ER, Begg CB, Kattan MW, Scardino PT. Departments of Urology, Memorial Sloan-Kettering Cancer Center, New York, New York, USA. PURPOSE: A strong association between surgeon, hospital volume and postoperative morbidity of radical prostatectomy has been demonstrated. While better outcomes are associated with high volume surgeons, the degree of variation in outcomes among surgeons has not been fully examined. MATERIALS AND METHODS: Using a linked database from Surveillance, Epidemiology and End Results registries and federal Medicare claims data, we analyzed outcomes of consecutive patients treated with radical prostatectomy between 1992 and 1996. We focused on variations in several measures of morbidity (perioperative complications, late urinary complications and long-term incontinence) among patients of high volume surgeons, defined as those with 20 or more patients in the study period. After adjusting for hospital, surgeon volume and case mix, we examined the extent to which variations in the rates of adverse outcomes differed among surgeons for all 3 end points. RESULTS: Of the 999 surgeons 16% (159) performed 48.7% (5,238) of the 10,737 radical prostatectomies during the study. The 30-day mortality rate was 0.5%, the major postoperative complication rate was 28.6%, late urinary complications 25.2% (major events 16%) and long-term incontinence 6.7%. For all 3 morbidity outcomes the variation among surgeons in the rate of complications was significantly greater than that expected by chance (p =0.001 for each) after adjustment of covariates. Furthermore, surgeons with better (or worse) than average results with regard to 1 outcome were likely to have better (or worse, respectively) results with regard to the other 2 outcome measures. CONCLUSIONS: Morbidity end points that directly affect quality of life showed significant variability among high volume providers. Surgeons who performed well in 1 area (eg postoperative complications) performed well in others. These results further suggest that variations in surgical technique and postoperative care lead to variations in outcomes after radical prostatectomy, indicating that outcomes of this operation are sensitive to small differences in performance. PMID: 15879851 It seems we can conclude from this study that we need both experience and competence. The first is not a guarantee of the second. I once had a knee operation from a guy who told me he had done 300 of them. I thought the outcome was a disaster, though of course the surgeon denied that anything went wrong. I remember that, while I was lying on the operating table and before the anaesthetics knocked me out, that I thought he was setting everything up extraordinarily quickly. It made me wonder if he had 300 knee operations alright, but all done at super high speed in one month. He was a regular hit and run artist. Alan Funny you mention that Alan. I almost went with another PC doctor before actually settling on the Head of Urology at the Cleveland Clinic who specializes in PC surgery. The other uro had lots of non robotic laparoscopic experience, and operated out Aventura Hospital, but I found him to be a bit of a marketeer. He even operated on Pat Robertson, for whatever that's worth. (Not much). I got the feeling that it was an assembly line and the guy had thousands upon thousands of excised bronzed prostates in his office. He advertised everywhere, with patient testimonials ad nauseam. B.A. You know, as a physician once in training (yearrrrrs ago), I have to wonder how newly trained surgeons are supposed to get their experience. What happens when the gurus retire? The "experienced" surgeons can train others, but then the new surgeon still has to get some cases done on his own. I don't disagree with the premise...going to the best you can find is a good idea and it just makes sense that more experience is better than less. In my town, the "most experienced" urologist for prostatectomy has decided to accept no insurance, he only does them for cash. That sort of places an economic filter that I don't agree with...let the inexperienced doctors operate on people who can't afford the best. Any thoughts? Sorry to ramble, I'm getting more disillusioned with our screwed up health care system in the U.S. by the day. CPW > You know, as a physician once in training (yearrrrrs ago), I have to > wonder how newly trained surgeons are supposed to get their experience. [quoted text clipped - 3 lines] > can find is a good idea and it just makes sense that more experience is > better than less. This is a particularly tough problem for sugery. In other fields you can screw up a little when you're a beginner and your seniors can make it right. Still, I sometimes prefer a doctor who doesn't know a lot but doesn't pretend he does, over an experienced but arrogant doctor. If a doctor tells me he doesn't know what my problem is but tries to look up my symptoms and do some research, I'm more impressed and interested in his services than in those of a doctor who always knows, or says he knows, what my problem is but won't do research. If a beginning surgeon reviews his books before the operation, thinks ahead, takes his time, and works carefully, I would think he'd likely do a pretty good job. I wouldn't choose him over an experienced doctor who also took his time, thought ahead and so on, but might choose him over an experienced hack. > In my town, the "most experienced" urologist for > prostatectomy has decided to accept no insurance, he only does them for > cash. That sort of places an economic filter that I don't agree > with...let the inexperienced doctors operate on people who can't afford > the best. Any thoughts? I understand why doctors get totally fed up with the !#$%^&* insurance companies. They lie, cheat, and steal from providers as a matter of policy. The essence of the insurance business consists in denying legitimate claims. The companies that get good at that survive and prosper. Personally, I think a doctor who has a position that enables him to get cash has a right to do that. But I think he also has an obligation not to turn away people who can't pay cash. I'd like to see him reserve some percentage of his business for people who pay with insurance, and at least some small percentage for people who can't pay at all. > Sorry to ramble, I'm getting more > disillusioned with our screwed up health care system in the U.S. by the > day. > CPW You're not the only one. For the money we pay (I can hear I.P. loading his guns now) we probably have the worst overall health care per dollar of any country. Alright, I've said it. Now I'm going to duck and run for cover. Alan > I understand why doctors get totally fed up with the !#$%^&* > insurance companies. They lie, cheat, and steal from providers > as a matter of policy. The essence of the insurance business > consists in denying legitimate claims. The companies that get > good at that survive and prosper. My "insurance company" is the federal government. It often takes more than a year to pay routine, unopposed insurance bills. I've had to call them up and pressure them to get off their a.ses and pay providers I felt were being ignored. The gum'mint said that's deliberate, that paying late saves them money. > Personally, I think a doctor who has a position that enables him > to get cash has a right to do that. But I think he also has an > obligation not to turn away people who can't pay cash. I'd like > to see him reserve some percentage of his business for people > who pay with insurance, and at least some small percentage for > people who can't pay at all. I'd LIKE to see that, too, but LIKING something and having the gum'mint MANDATING it are a different as headaches and cancer, IMO, as long as the doc paid his own way through med school. > You're not the only one. For the money we pay (I can hear I.P. > loading his guns now) we probably have the worst overall health > care per dollar of any country. I have no data to load into my guns, but infinitely greater students than I of that issue rate our medical system as the best in the world, and I presume cost plays some factor in that statement, so it must stack up pretty well. What I understand even less is the cost of medical insurance. U.S. News & World Report sez coverage for a family of 4 can cost UP TO $10k a year; my brother pays $18k + $7k deductible for himself and his wife. What's a norm? I.P. > ... > My "insurance company" is the federal government. It often takes more than a year to pay > routine, unopposed insurance bills. I've had to call them up and pressure them to get > off their a.ses and pay providers I felt were being ignored. The gum'mint said that's > deliberate, that paying late saves them money. > ... Yes. The government is just as bad and often worse than the private insurers. They underfund the programs and then tell the people whose line job it is to pay out the funds - This is the money you've got. Don't tell me it isn't enough. That's your problem. Do whatever you have to do. So they do the same things the private insurers do. >> Personally, I think a doctor who has a position that enables him >> to get cash has a right to do that. But I think he also has an [quoted text clipped - 6 lines] > a different as headaches and cancer, IMO, as long as the doc paid his own way through > med school. I have to reluctantly agree with this. Reluctantly because I'd like to kick some of the rich doctors in the butt and show them some suffering people. But I agree nevertheless. If we want a free country then we have to give people freedom. >> You're not the only one. For the money we pay (I can hear I.P. >> loading his guns now) we probably have the worst overall health [quoted text clipped - 3 lines] > issue rate our medical system as the best in the world, and I presume cost plays some > factor in that statement, so it must stack up pretty well. That was a pretty mild response I.P. I think you're mellowing. But I am too. Life is too short for flame wars and besides, I've developed too much respect for the people who disagree with me to take shots at them. I _think_ the things I believe are right or I wouldn't believe them. But I'm not so impressed with myself as to imagine that everything I believe actually _is_ right, or that the people I disagree with are always wrong. > What I understand even less is the cost of medical insurance. U.S. News & World Report > sez coverage for a family of 4 can cost UP TO $10k a year; my brother pays $18k + $7k > deductible for himself and his wife. What's a norm? Yes. I'm now being charged $12K/year for myself and my wife by Kaiser for HMO coverage. It's a substantial fraction of my income. Add copays, dental bills (not covered) drugs (mostly not covered) etc., and it's no joke. The biggest medical expense I ever had cost Kaiser very little since I got treated for free in an NCI clinical trial. Maybe I should get a long, costly, debilitating illness just to get my money's worth. :) Interestingly, one of the reasons that the U.S. is having trouble competing in international trade is the huge health care costs borne by industry. In two of our big trade creditors - China and Japan - the government pays most of that and industry gets a free ride. This is part of the hidden cost of the kind of private medical insurance we have in the U.S. Alan > Yes. The government is just as bad and often worse than the private > insurers. They underfund the programs and then tell the people > whose line job it is to pay out the funds - This is the money you've > got. Don't tell me it isn't enough. That's your problem. Do whatever > you have to do. Ain't my problem. I intervene only because it's the right thing to do when the government is sticking it to an insurer. >> I have no data to load into my guns, but infinitely greater students than I of that >> issue rate our medical system as the best in the world, and I presume cost plays some >> factor in that statement, so it must stack up pretty well. > > That was a pretty mild response I.P. I think you're mellowing. A. I promised I would. B. I don't know the facts because I'm still two years from facing the choices. I.P. > You know, as a physician once in training (yearrrrrs ago), I have to > wonder how newly trained surgeons are supposed to get their experience. [quoted text clipped - 9 lines] > disillusioned with our screwed up health care system in the U.S. by the > day. It's called capitalism, and it works far better than even the best alternative, let alone that alternative's evil cousin. What exceptional college kid would want to become a physician if all it meant was turning a bureaucratic crank with no chance to excel and going to prison if Bill Gates chose her personally to replace his heart because she was the best? What's wrong with them that succeeds having options the less successful don't? Where ELSE would we have any motivation to excel? Without that motivation, why would anyone bust his hump to excel -- to stay off drugs, finish school, hump multiple or challenging jobs, work 100 hours a week in his garage to change the world by inventing the PC, create hundreds of thousands of jobs, etc.? Without that, wouldn't he bar just creep ever lower as people saw ever-decreasing rewards for raising it? You think I'd have let VA surgeons remove my prostate or cochlea, or a VA doc diagnose and treat anything more challenging than a broken finger? Isn't the major sources of physicians' disillusionment we read about is ... ta da ... government intervention? And what program has the gum'mint ever done better than private, competitive industry could or did? I.P. Yeah, yeah, yeah...capitalism is great. The fact remains that the less advantaged in our country don't deserve poorer quality health care just because they can't pay for it. I don't necessarily think that access to health care is a "god-given right", but success in business doesn't necessarily have to equate with equal access to services. A CLOSET DEMOCRAT. CPW Yeah, yeah, yeah...capitalism is great. The fact remains that the less advantaged in our country don't deserve poorer quality health care just because they can't pay for it. I don't necessarily think that access to health care is a "god-given right", but success in business doesn't necessarily have to equate with equal access to services. A CLOSET DEMOCRAT. CPW > You know, as a physician once in training (yearrrrrs ago), I have to > wonder how newly trained surgeons are supposed to get their experience. [quoted text clipped - 9 lines] > disillusioned with our screwed up health care system in the U.S. by the > day. Experience is experience. It is what it is. Those who have it are better than those who don't. Those who associate themselves with people who have it, usually benefit from it more than those who associate themselves with those who don't. It's life. I never had a chance at Walsh, Strum or Scardino. I had to settle for Shank, and I'm happy to have done so. I think of the 3 Billion men in the world, I was pretty lucky to be paired up with him, but I suspect billions won't have that opportunity. Nor have billions been able to take advantage of the experience of Dr. Williams. If you're rich or run for president, you get a choice. For the rest of us, it's a crap shoot unless we dig hard to find the best available to us. Steve Kramer wrote...snip... > Experience is experience. It is what it is. Those who have it are better > than those who don't. Steve...I don't think that's always true. That was the point of the abstract in my post up above...Ron > Experience is experience. It is what it is. Those who have it are better > than those who don't. Those who associate themselves with people who have > it, usually benefit from it more than those who associate themselves with > those who don't. There's a huge area between those extremes, and plenty of hacks who have done thousands of RPs. > I never had a chance at Walsh, Strum or Scardino. ... > If you're rich or run for president, you get a choice. For the rest of us, > it's a crap shoot unless we dig hard to find the best available to us. Not necessarily. I was told I could choose any surgeon at the research/teaching hospital I had chosen, and I could have chosen any hospital AFAIK. I simply wasn't willing to fly and drive and schlep to Hellenbach to MAYBE change the stats by a few points. For all I know I got one of the best uro/onc/surgeons on the planet, even though it's becoming obvious I'll never be free of pads. I.P. > You know, as a physician once in training (yearrrrrs ago), I have to > wonder how newly trained surgeons are supposed to get their experience. [quoted text clipped - 10 lines] > day. > CPW My doc (at over 1000 RPs as of Dec 02) assists other doctors in surgery in addition to other surgeons assisting him. I would think that is how a less experienced surgeon acquires more experience. It's a team effort where everybody gains experience working together. Dale j.  SignatureEmail: dalej2@mac.com > My doc (at over 1000 RPs as of Dec 02) assists other doctors in surgery > in addition to other surgeons assisting him. I would think that is how > a less experienced surgeon acquires more experience. It's a team effort > where everybody gains experience working together. Absolutely, Dale, and that's how it should be done. However, when the patient asks, "How many of these have you done?", saying "1000" beats saying "I've assisted in ____" by a long way. My original post was meant to reflect what you are saying...I think...in that absolute numbers don't always convey an accurate measure of a surgeon's competence, as others have stated here. CPW |
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