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Thanks for keeping us up-to-date on what's going on there.
I just read the "Is surgery best reserved for first-line treatment of higher-risk prostate cancers" article. What percentage of men that typically have surgery is he talking about, the ones he says might be better off NOT having surgery, it must be very high. Am I right, he's saying the typical GS6 patient might be better off NOT having surgery.
To be honest I find his report to be very disturbing. Not only does he say that surgery might not be the best treatment for most PCa patients, he also makes the point that most doctors performing the surgery probably aren't doing as good a job as they should. By that I mean the statements he made that it takes about 250 surgeries to do it well, and then the surgeon improves his technique for 1,000 surgeries. So how many surgeons does that knock out of our consideration? Maybe surgeons should start flying in to do a prostatectomy, that way we can get the best surgery anywhere we are.
Another question I have, he says, and I quote.
• Within the MSKCC database, there is clear evidence that laparoscopic surgery has been associated with lower levels of continence and a greater risk for readmissions for additional surgery than open surgery
So what type of laparoscopic surgery is he talking about, normal or robotic? This is not good, he says continence, not in-continence. So which ever it is doesn't seem to have a good track record. I assume he's talking about normal laparoscopic surgery?
I have to say this is a must read article for any prostate cancer patient, especially newly diagnosed. I'm going to add a large quote from the end.
START QUOTE
Also during the course of this presentation, Scardino more than once makes the point that surgery is so successful at preventing prostate cancer-specific deaths for patients with low-risk disease that “one has to ask oneself” whether many of those patients couldn’t just be monitored and treated later if necessary.
There would be little argument in the urologic oncology community that Dr. Scardino is one of the very best prostate cancer surgeons of his generation — if not the best. For him to be making a presentation of this type with this degree of clarity would again suggest to The “New” Prostate Cancer InfoLink that there is a major mindset shift taking place in the urology community about who really should get immediate surgical treatment for very early stage prostate cancer. It is clear that Dr. Scardino and his colleagues at MSKCC have already come to some specific conclusions — although they may still find themselves under pressure from newly diagnosed, low-risk patients to “just get it outta there.”
Is surgery best reserved for first-line treatment of higher-risk prostate cancers
Stranger,
I’m not to sure if you followed the link to the actual presentation? I suspect not.
In answer to your specific questions and comments:
1. What percentage of men that typically have surgery is he talking about, the ones he says might be better off NOT having surgery, it must be very high. Yes it is. I don’t have time to listen to his presentation again, but I recall that he presented some data in this regard.
2. Am I right, he's saying the typical GS6 patient might be better off NOT having surgery. What Dr Scardino says in effect is that although there is clear evidence that surgery DOES save lives, the number of ‘low risk’ patients who would have died from PCa be better off to retain their quality of life by avoiding surgery. Nothing new in that – it’s just unusual to hear one of the best surgeons in rthe US say it so clearly.
3. …..it takes about 250 surgeries to do it well, and then the surgeon improves his technique for 1,000 surgeries. So how many surgeons does that knock out of our consideration? Most of them. There have been two recent studies published in this regard. Here is one:
J Urol. 2009 Dec;182(6):2677-9.
Low annual caseloads of United States surgeons conducting radical prostatectomy.
Savage CJ, Vickers AJ.
Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, New York 10021, USA
PURPOSE: It has been clearly demonstrated that surgeons with increased yearly caseloads have lower complication rates. Moreover it has been shown that a surgeon needs to conduct at least 250 radical prostatectomies to maximize cancer control (the surgical learning curve).
MATERIALS AND METHODS: To determine typical annual radical prostatectomy caseloads of surgeons in the United States we analyzed data from 2 independent data sets for 2005, that of a nationally representative sample (Nationwide Inpatient Sample) and a complete record of all hospital discharges from New York State (Statewide Planning and Research Cooperative System).
RESULTS: More than 25% of United States surgeons conducting radical prostatectomy in 2005 performed only a single procedure. Approximately 80% of surgeons performed fewer than 10 procedures per year and, thus, are unlikely to reach the plateau of the learning curve during their surgical career.
CONCLUSIONS: The current pattern of surgical treatment for prostate cancer leads to many patients being treated by surgeons with low annual caseloads, with likely poorer outcomes as a result.
PMID: 19836787 [PubMed - indexed for MEDLINE
I can’t track the other one right now, but recall the conclusion that less than 60% of PCa surgeons had done more than 50 procedures. The figure of 250 procedures as a minimum required for competence was mentioned, with the rider that results continued to improve until the man had done at least 1,000 procedures.
This lack of experience is one of the reasons why the experience of most men with regard to final outcome and side effects differ markedly from published studies, most of which are in respect of the outcome of very experienced surgeons.
4. As to laparoscopic surgery, it seems he was talking about both robotic and manual, but there is a lack of clarity as to whether the comparisons he made were valid because it was not clear if the surgeons in each group of the study were similarly experienced.
I feel I should mention that Dr Catalona also made a presentation at the same conference in which he put forward very strongly his views on screening and surgery which were basically that there should be more screening and that every man diagnosed with organ contained prostate cancer should have surgery.
Both of these presentations have been widely discussed on the PPML mailing list with opposing views being made for both. I think such discussions are very useful. Others feel they waste time and create confusion.
Re: Is surgery best reserved for first-line treatment of higher-risk prostate cancers
Terry,
Thanks for your reply, as always it was filled with good stuff. You said...
I feel I should mention that Dr Catalona also made a presentation at the same conference in which he put forward very strongly his views on screening and surgery which were basically that there should be more screening and that every man diagnosed with organ contained prostate cancer should have surgery.
It doesn't surprise me that Dr. Catalona said that, that's his baby, PSA Screening and Surgery. There's a mountain of evidence piling up against him, but he continues to beat the same drum. Dr. Scardino said this...
One of the characteristics of a great clinician is the ability to continue to learn, to revise one’s opinions, and even radically change one’s mind based on experience.
I think he's right, but I also feel most Doctors refuse to change their initial opinion. It's clear that Dr. Stamey changed his view after doing years of research. Dr. Stamey is the father of PSA Testing (not screening) and his view changed after years of research. Now other Doctors are starting to change their view too, but Dr. Catalona will probably always stick to his initial view no matter what evidence piles up against them.
You're right I didn't follow the link because I didn't have a logon to see the presentation. But I probably should have. I did follow the link today about Dr. Eastham's article, PSA Testing and the Spectrum of Risk in Prostate Cancer. I had to create a new account to read it and after I read it it seemed old hat to me, it seems the same stuff is said over and over. But a person that hasn't read much about PCa would have probably liked it. I mean how many times can you say... Testing and Screening does save lives... Sometimes. An over simplification I know, but true none the less. I'm a simple guy so forgive me for cutting to the chase.
You said...
Both of these presentations have been widely discussed on the PPML mailing list with opposing views being made for both. I think such discussions are very useful. Others feel they waste time and create confusion.
I bet there were opposing views. To me the real issue is, quality of life vs length of life. If you want to live as long as possible then treatment is the only option now, since they can't prove which cancers are life threatening. If the man is unwilling to accept any risk then immediate treatment is all that's left. Again I'm cutting to the chase to save typing.
Re: Is surgery best reserved for first-line treatment of higher-risk prostate cancers
Obviously which of any method is best and for what type of patient, or even w.w. or refusing treatments is also someones personal choice?
Since the experts cannot agree on even about what is the better testing proceedures even as a screening type of protocol, we are left grabbing at straws and listening to biased advice from most all sources.
Based on what limited knowledge I have on PCa, our PCa screening choices as to having a measurable value for ascertaining right now...what are you dealing with:
1. psa tests (history needed, velocity needed)
2. fpsa testing or other types (data needed)
3. PCa-3 testing (atleast know the possible results)
4. guided biopsies (assuming you have PCa present)
5. have pathology reviewed by experts, maybe 2 of them
6. pay for pathology ploidity testing or other data
7. consider scans beyond the ct and bone scans (usually those are not worthy enough), consider color doppler ultrasound for possible location of PCa.
8. consider going to Holland for Combidex scanning to find location(s) of PCa, possiblly detect lymphnodes envolved and more precise data (needed to assess)
8/9. see Partin tables, bluestein, narayan, nomograms
9. another consideration is lymphendectomy/sampling of a few nodes for PCa (does have risks too)
10. then consider looking at all possible protocols including non-invasive, so (what drugs or other protocols are found useful?)
11. then decide on your course of action of your hopefully educated...plan of action and life style.
12. then monitor for life and still question everything, but atleast know you did your best.
Robert Young called it (the "jungle"), I am adding it is the "twilight zone" and patients living with PCa usually find themselves living in "limbo-land" you don't know for certain where you stand (recurrence is possible even after 10+ yrs.)...PCa is a "dragon"
This is how it appears in my experiences.
