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NEWS & VIEWS |
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Men who choose radical prostatectomy as treatment for prostate cancer should seek out a surgeon with many of these procedures under his or her belt, researchers from 3 major cancer centers say. Their recent study (JNCI 2007;99:1171–1177) finds that more surgeon experience translates into a lower probability of recurrence for the patient.
In fact, they calculated that a man operated on by a surgeon who has performed 250 or more prostatectomies has an absolute risk of recurrence 7.2% lower than one treated by a surgeon who has performed 10 or fewer prostatectomies. That difference is both statistically significant and clinically important, says lead study author Andrew Vickers, PhD, Associate Attending Research Methodologist at Memorial Sloan-Kettering.
"This is the sort of thing that if we saw it in a drug, we'd be totally blown away by," says Vickers.
The findings are based on records of 7,765 men treated by one of 72 surgeons between 1987 and 2003. The surgeons were from 4 participating institutions: Memorial Sloan-Kettering Cancer Center in New York, Baylor College of Medicine in Houston, Wayne State University in Detroit, and the Cleveland Clinic in Cleveland, Ohio. Vickers and his colleagues wanted to know whether the number of radical prostatectomies the surgeons had performed over the course of their careers influenced the likelihood of prostate cancer recurrences in their patients.
Most of the surgeons (57%) had performed fewer than 50 prostatectomies, just 11% had done 250 to 999, and 3% had performed more than 1,000. There were 1,256 biochemical recurrences among the patients during a median 3.9 years of follow up.
Vickers and his colleagues calculated the 5-year probability of recurrence at 17.9% for men treated by a surgeon who had performed 10 or fewer prostatectomies and 10.7% for men treated by a surgeon with 250 prior operations (P < 0.001). This difference remained even after controlling for possible differences in case mix, the year the surgery was performed (to account for the impact of stage shift resulting from widespread implementation of prostate-specific antigen testing), and tumor pathology.
The likelihood of a patient remaining cancer-free increased steadily and sharply with the number of surgeries performed until leveling off at 250 procedures.
Although many studies have examined outcomes related to surgeon volume, this one stands out because it looked at surgery as a sole treatment and because its endpoint was biochemical recurrence, rather than death (which can be influenced by comorbidities, postoperative care, adjuvant therapies, and other factors unrelated to surgical technique), Vickers says. Rising levels of prostate-specific antigen after surgery are a good indicator of the surgery's success, and because no adjuvant or neoadjuvant treatment was given, surgical technique is the primary factor likely to affect recurrence.
"We think we're really able to identify an effect on patient outcome based on differing surgical techniques," he adds.
Just what surgical techniques are most effective is a matter that requires further study. Vickers says clinical trials comparing different techniques should be organized in the same way studies explore the efficacy of different chemotherapy regimens.
The medical community should also reconsider how surgeons are trained, he says, perhaps by incorporating practical clinical training into continuing medical education programs that surgeons must take after completing their residency. This would also allow surgeons to receive important feedback on their technique from more experienced colleagues that could help them improve their performance, ultimately benefiting their patients.
Thought also should be given to reorganizing cancer care in a way that makes it easier for patients to gain access to the most experienced surgeons, Vickers says. Among urologists practicing in community settings, it is not uncommon to find physicians who perform only a handful of prostatectomies each year. For instance, statistics compiled by the New York-based nonprofit Center for Medical Consumers using that state's Statewide Planning and Research Cooperative System database and other surgical databases shows that in 2002, some 60% of surgeons performing radical prostatectomies had done 5 or fewer procedures that year.
"Is it appropriate that some people with prostate cancer are being treated by surgeons who will never develop sufficient experience to conduct the operation as well as it can be done?" Vickers asks.
Perhaps prostate cancer care could be regionalized so that the majority of patients are treated at a handful of centers or groups of doctors specializing in the disease.
Regardless, patients should be advised to choose the most experienced surgeon they can find, Vickers says.
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