I have a confession to make: I am not a big fan of “gee whiz” medical technology. At least not until it is proven to really make a difference in the care we provide our patients, or the outcomes of their treatments.
A study in yesterday’s Journal of the American Medical Association comparing the side effects and outcomes of prostate cancer surgery using the robot to more traditional surgery reinforces that notion.
Using the robot to treat prostate cancer surgically may be better in some respects, but not better in others. And maybe not better enough for you to listen to all of the advertising hype about the robot, and forego treatment from a urologic surgeon who in fact may be more skilled at the operation and not use the robot.
The study was reasonably straight forward. The researchers looked at patient information they obtained from a highly respected national cancer database called SEER and matched those men diagnosed and treated surgically for prostate cancer with another set of data obtained from Medicare fee-for service Part B billing records.
Once they matched the men in both sets of records, they looked at factors related to treatment and outcome, such as how long the men stayed in the hospital and what complications they had over the year following their operation.
Their goal was to evaluate men who had surgical treatment for their prostate cancer one of two ways: with the robot, which is called “minimally invasive radical prostatectomy”, (MIRP) done with instruments passed through small holes and manipulated by a urologist who is sitting at a special machine, compared to men who had their surgery the more traditional way, called “retropubic radical prostatectomy” (RRP) where the surgeon is standing directly by the patient and operating through a more typical (but still fairly small) incision.
Both of these operations remove the cancerous prostate, and--when appropriate—allow the surgeon to remove lymph nodes nearby the prostate. Both are designed to reduce the risk of impotence, which many years ago was a common problem for men who had prostate cancer surgery before newer types of surgical treatment were developed.
The robotic surgery is very new, and has only been used to any significant degree to treat prostate cancer since the early part of this decade. But it clearly has caught the attention of the public, and hospitals across the country can’t seem to wait to get their hands on one of these machines and advertise that they are a “robotic center” to accommodate the patient demand.
The problem is that these machines cost millions of dollars, and the disposable equipment sold for each operation has made the company that supplies these machines a heck of a lot of money. That in turn means more costs for hospitals, health insurance companies, and ultimately the patients. It also takes longer to do the robotic operation, according to my colleagues who perform this surgery.
So, whether or not these machines are really worth it is a very important question. Not to mention that the increasing concerns about the value of the PSA test has run head long into the reality that prostate cancer treatment in this country has turned into a huge business for doctors and hospitals—whether or not the treatment is necessary.
(That issue was highlighted recently by a hospital in Philadelphia offering PSA screening to men 35 years and older, despite absolutely no proof that this was of any value to men in this age group. As with most community screening fairs run by hospitals, I suspect that one of the major drivers for that campaign was probably to “feed the beast” rather than offer scientifically valid screening to men at risk.)
So what did the study find?
There has been a huge increase in MIRP from 9.2% of prostate cancer surgeries in 2003 to 43.2% in 2206-2007. However, if you were poor and/or black or Hispanic and/or less educated, you were less likely to get one of these fancy surgeries.
You were likely to spend one day less in the hospital with the robot (2 vs. 3 days), less likely to have a blood transfusion after surgery, and more likely to do a bit better with regard to surgical complications post-operatively. But the authors also suggested that the number of days in the hospital may in fact be similar in high volume hospitals, so whether or not this difference is “real” is not certain.
Another wrinkle to consider in this study was that many of the robotic procedures in this study were performed in Detroit and California, which the authors point out are high volume robotic centers. This may have contributed to the better outcomes for MIRP, compared to RRP which is done by more surgeons in more locations. As they say in the weight-loss commercials: “These (robot) results may not represent the typical experience with our product”. (Detroit, in fact, was one of the “homes” of robotic prostate cancer surgery because of a surgeon there who was nationally renowned for his early work with the robot.)
But the robot did not fare better on every measure.
You were over twice as likely to have a problem with your urinary tract after the robotic surgery, and have a higher risk of urinary incontinence (controlling your urine flow) compared to the non-robotic technique. Your risk of having impotence after the robot surgery was about one in four, compared to one in five with the more traditional surgery.
Unlike a previous study where the men operated on with the robot were more likely to have an earlier relapse of their prostate cancer and require additional treatment for the spread of prostate cancer compared to men who had traditional surgery, this study showed that both groups did the same. When it came to the control of prostate cancer, there was no advantage to one type of surgery compared to the other.
So what do you do if you are a man diagnosed with prostate cancer who has made an informed decision to have surgery for your disease?
I guess for some of you the decision will come down to the old adage “you pay your money and you make your choice.” You may decide that how long you stay in the hospital is more important than the difference in whether or not you can control your urine flow or are able to have sexual relations.
But I think there is a more rational recommendation that actually may surprise you: I suggest you find a surgeon who does either procedure regularly and has done hundreds—if not thousands—of prostate surgeries for cancer. To me, it is experience that counts not whether the procedure is done with or without the robot.
The bottom line is that you can have a great surgeon who doesn’t use the robot, or a lousy surgeon who uses the robot—and vice versa. The robot does not make an inexperienced surgeon better. It’s that simple.
Take a moment to read this information that was contained in the JAMA paper, and read it carefully. It is very informative and something that every man considering prostate surgery who has succumbed to the advertising and hype surrounding this robotic procedure needs to know:
“For surgeons eager to add robotic-assisted MIRP to their armamentarium, there are few barriers to entry: surgeons must attend a 2-day course before scheduling cases proctored by another surgeon who has performed at least 20 robotic-assisted MIRPs. Requirements may be less rigorous for attaining hospital privileges for MIRP without robotic assistance*. Studies estimate the learning curve for either approach is at least 150-250 cases, and greater RRP or MIRP surgical volume is associated with better outcomes.”
(*Note: That means doing the prostate surgery laparoscopically without using the robot)
I would suggest that if you need to get surgery for your prostate cancer using either type of surgery, you make certain you are not case #21. You should be at least case #250, and I would prefer to be case #500 or higher.
Here is what the authors have to say in concluding their report:
“In light of the mixed outcomes associated with MIRP, our finding that men of higher socioeconomic status opted for a high-technology alternative despite insufficient data demonstrating superiority over an established gold standard may be a reflection of a society and health care system armored with new technology that increased direct and indirect health care costs but had yet to uniformly realize marketed or potential benefits during early adoption.”
In other words, many of us buy the hype and forget the reality that just because it looks fancy doesn’t mean it really gives you a better result. We are medical consumers run amok, dazzled by ads and unsubstantiated claims rather than by science and documented outcomes. If we see it on TV or a billboard, it must be better.
The science tells me it is the experience of the surgeon that counts, not whether the doctor can play video games.
So, if you decide to get your prostate taken out because you have cancer, go with a surgeon that has done the surgery lots of times, whether or not they use a robot. You don't have to be uncomfortable if you want to leave the video games to the kids.