How many surgeries are enough?

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clocknut
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   Posted 1/16/2011 3:44 PM (GMT -6)   

I just did a little Googling regarding the learning curve for DaVinci prostatectomies.  So far, everything I've found seems to point to no significant improvement in outcomes after a rather low number of robotic procedures  Most of the studies I've read reach a conclusion similar to the following:  "Conclusion: RALP is a feasible and reproducible technique, with a short learning curve and low perioperative complication rate. Even during the initial phase of the learning curve, good results were obtained with regard to postoperative complications and oncological outcome."  The link to the abstract of this study is here:  http://adsabs.harvard.edu/abs/2007SPIE.6424E..26L

I've only been visiting HW for five months, but I must say I've seen as many negative outcomes from big-name, well known cancer centers as I've seen from anywhere. 

I'm not trying to be contrary here, and of course I believe we all want a competent surgeon, but just where does this idea that the surgeon must have performed 700, or 1000, or 3000 surgeries in order for us to have confidence in his abilities originate?  Can someone please point me to objective proof of this assertion?

Post Edited (clocknut) : 1/16/2011 2:06:24 PM (GMT-7)


Casey59
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Date Joined Sep 2009
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   Posted 1/16/2011 4:24 PM (GMT -6)   
clocknut said...

How many surgeries are enough?

There is no one number which is universially accepted as "enough."  One can get the mechanics down after the numbers discussed in the study you supplied, and the overall surgery time and blood-loss will begin to stabilize.  However, more desirable is a surgeon who has "seen it all", and successfully navigated through a wide variety of both simple and complex surgeries.
 
 
clocknut said...

...but I must say I've seen as many negative outcomes from big-name, well known cancer centers as I've seen from anywhere. 

Hmmm...you probably haven't seen enough

Postop
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Date Joined Feb 2010
Total Posts : 385
   Posted 1/16/2011 6:03 PM (GMT -6)   
There are definitely studies showing the learning curve over hundreds of operations here.   They've been discussed here multiple times before.  The trouble with this HW forum is that its memory only lasts a few days, and it is impossible to search and find these old posts.  The same issues and questions pop up over and over again; sometimes the best answer gets posted, sometims not.  Someone needs to set up a system of keywords and search functions so old answers can be effectively recycled.
 
In the meantime, someone needs to pop up and reanswer this question.

Tudpock18
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Date Joined Sep 2008
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   Posted 1/16/2011 6:14 PM (GMT -6)   
Here is the re-answer to the best of my ability.  I posted this in the Fall of 2008 and have re-posted it several times since.  This was as quoted in the Johns Hopkins Health Bulletin:
 

The importance of surgeon's experience as it relates to prostate cancer outcome is underscored by the results of a study reported in the Journal of the National Cancer Institute (volume 99, page 1171).

Researchers analyzed the outcomes of 7,765 radical prostatectomies performed by 72 surgeons between January 1987 and December 2003 at four major academic medical centers. "Biochemical" recurrence was defined as a postsurgery PSA level greater than 0.4 ng/mL followed by a subsequent higher PSA level. The analysis took into account patient and tumor characteristics, such as pre-operative PSA level and Gleason grade. The men's PSA levels were measured every three to four months in the first year after surgery, twice in the second year, and annually during the following years.

The researchers found that surgical outcomes improved along with the number of radical prostatectomies a surgeon had performed, leveling off only after about 250 surgeries. The five-year probability of experiencing a recurrence of prostate cancer was 18% for surgeons who had performed only 10 operations compared with 11% for surgeons who had performed at least 250 surgeries.

Bottom line on prostate cancer surgery: The results suggest that you can improve your odds of a successful outcome from radical prostatectomy by taking time to find a surgeon with extensive experience.

So, with all due respect to the 170 operations by one surgeon in the study quoted by clocknut, the NCI data is fairly compelling.  Of course one might argue that this is not specific to robotic surgery and that would be true.  However, one might also argue that robotic requires extensive skills and that the learning curve is equally steep.  There may be other specific studies and I will be interested if other find them.  In any case, based on this extensive study quoted above, it will continue to be my advice to posters to find a highly experienced physician. 

 

Tudpock (Jim)



Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 12/8/10. PSA: 6 mo 1.4, 1 yr. 1.0, 2 yr. .8. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1305643

Jazzman1
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Date Joined Sep 2010
Total Posts : 1162
   Posted 1/16/2011 7:04 PM (GMT -6)   
My doctor's totally subjective view is that the learning curve pretty much flattens out after about 250 surgeries. Your mileage may vary.

Purgatory
Elite Member


Date Joined Oct 2008
Total Posts : 25393
   Posted 1/16/2011 9:01 PM (GMT -6)   
Too many here get hung up on some specific number, you need to ask youself about the quality of the operations too. Less with a highly skilled surgeon may be better than someone running a surgery mill where they are all lined up like cord wood.

And clock is right, there is more than one guy here, that went to the best of the best hospital, had the best of the best doctor (supposedly) and ended up with miserable results. Even that is no guarantee of sucess.

David
Age: 58, 56 dx, PSA: 7/07 5.8, 10/08 16.3
3rd Biopsy: 9/08 7 of 7 Positive, 40-90%, Gleason 4+3
open RP: 11/08, on catheters for 101 days
Path Rpt: Gleason 3+4, pT2c, 42g, 20% cancer, 1 pos marg
Incont & ED: None
Post Surgery PSA: 2/09 .05,5/09 .1, 6/09 .11. 8/09 .16
Post SRT PSA: 1/10 .12, 4/8 .04, 8/6 .06 11/10 Not taking it
Latest: 6 Corr Surgeries to Bladder Neck, SP Catheter since 10/1/9, SRT 39 Sess/72 gy ended 11/09, 21 Catheters, Ileal Conduit Surgery 9/23/10

Sleepless09
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Date Joined Jul 2009
Total Posts : 1267
   Posted 1/16/2011 9:21 PM (GMT -6)   
My surgeon had lots of experience with both open, laparoscopic (before robots) and then with da Vinci.

However, another da Vinci surgeon, also with lots of experience, said that patients needed to go beyond numbers and really check out a surgeon with people like anesthetists, OR nurses, pathologists, and the nurses who work the urological surgical wards. Find out who doctors are going to when they need surgery.

As for numbers, she said surgery was not unlike baking a chocolate cake. Some people could bake a great cake quickly, others baked awful cakes 500 cakes later. As I had a relative who thought she could make great cakes, which cakes might be useful for putting under spinning wheels when stuck, but not much more, and who must have made thousands of these rock hard cakes, I knew what she was talking about.

My wife's father was an anesthetist, my wife an OR nurse. From dinner table conversation I'm quite convinced that not all surgeons are created equal --- that substantial differences exist in skill and outcomes. And sometimes it is the ones with lots of experience who would be last on the list my father-in-law, or wife, would choose.

I think numbers of surgeries are interesting, and certainly a factor, but I worry that reliance on numbers could lead to a too superficial due dilgence if people put too much emphasis on simple numbers and not results.

Sheldon AKA Sleepless
Age 67 in Apil '09 at news of 4 of 12 cores positive T2B and Gleason 3 + 3 and 5% to 25% PSA 1.5
Re-read of slides in June said Gleason 3 + 4 same four cores 5% to 15%
June 29 daVinci prostatectomy, Dr. Eric Estey, at Royal Alexandra Hospital Edmonton one night stay
From "knock out" to wake up in recovery less than two hours.  Actual surgery 70 minutes
Flew home to Winnipeg on July 3 after 5 nights in Ramada Inn  ---  perfect recovery spot!
Catheter out July 9
Final pathology is 3 + 4 Gleason 7, clear margins, clear nodes, T2C, sugeron says report is "excellent"
 
Oct 1st 09 -- dry at night, during day some stress issues.
Oct 31st padless 24/7 
 
First post op PSA Sept 09  less than 0.02
PSA on Oct 23, 2009 less than 0.02
PSA on Jan 8, 2010  less than 0.02
PSA on April 9, 2010 less than 0.02 
PSA on July 9, 2010 (one year) less than 0.02
  

Sleepless09
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Date Joined Jul 2009
Total Posts : 1267
   Posted 1/16/2011 9:24 PM (GMT -6)   
While I was typing the above, and doing my daily exercise watching a movie on TV, David posted.

Better I should have just said, "I agree with David."

Matter-of-fact, I could just go on record as, "I agree with David," as being my take on everything here.

Sheldon AKA Sleepless
Age 67 in Apil '09 at news of 4 of 12 cores positive T2B and Gleason 3 + 3 and 5% to 25% PSA 1.5
Re-read of slides in June said Gleason 3 + 4 same four cores 5% to 15%
June 29 daVinci prostatectomy, Dr. Eric Estey, at Royal Alexandra Hospital Edmonton one night stay
From "knock out" to wake up in recovery less than two hours.  Actual surgery 70 minutes
Flew home to Winnipeg on July 3 after 5 nights in Ramada Inn  ---  perfect recovery spot!
Catheter out July 9
Final pathology is 3 + 4 Gleason 7, clear margins, clear nodes, T2C, sugeron says report is "excellent"
 
Oct 1st 09 -- dry at night, during day some stress issues.
Oct 31st padless 24/7 
 
First post op PSA Sept 09  less than 0.02
PSA on Oct 23, 2009 less than 0.02
PSA on Jan 8, 2010  less than 0.02
PSA on April 9, 2010 less than 0.02 
PSA on July 9, 2010 (one year) less than 0.02
  

clocknut
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Date Joined Sep 2010
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   Posted 1/16/2011 10:07 PM (GMT -6)   

I brought this question up when I saw new member "Robs" being advised that the surgeon he had chosen, a surgeon who has done 450 prostatecomies, 150 of which were DaVinci and the other 300 open, was probably not sufficiently experienced, and that he should find someone who has done at least 700, or better yet 1,000 DaVinci procedures.

I felt badly for "Robs."  If I had gotten that sort of answer five months ago, when I was getting ready for surgery, I'd have been thoroughly demoralized.  "Robs" was given a lot of good advice, but it was clear to me that in terms of selecting a surgeon, he had done his due diligence, he had selected a surgeon with great care and after thorough consideration, and that he was looking for approval and reinforcement regarding his decision.  He said that his doctor has a wonderful reputation among his peers.

I realize that we all want to stress to newcomers the importance of choosing the best surgeon available to them.  But if we start giving these folks the impression that they're taking a great risk if their surgeon hasn't done at least 700 or 1000 procedures, I think we've raised the bar way too high.


Newporter
Regular Member


Date Joined Sep 2010
Total Posts : 225
   Posted 1/16/2011 10:31 PM (GMT -6)   
I went back to my research files I collected after my PCa dx in June 2010 and look for some information on this topic. One of the papers I collected and reviewed is summarized as follows:

Surgeon experience is strongly associated with biochemical recurrence after radical prostatectomy for all preoperative risk categories.
Klein EA, Bianco FJ, Serio AM, Eastham JA, Kattan MW, Pontes JE, Vickers AJ, Scardino PT. Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, Ohio, USA. kleine@ccf.org Comment in:
J Urol. 2008 Dec;180(6):2716-7; author reply 2717-8.

Abstract

PURPOSE: We have previously reported that there is a learning curve for open radical prostatectomy. In the current study we determined whether the effects of the learning curve are modified by patient risk, as defined by preoperative tumor characteristics.

MATERIALS AND METHODS: The study included 7,683 eligible patients with prostate cancer treated with open radical prostatectomy by 1 of 72 surgeons. Surgeon experience was coded as the total prior number of radical prostatectomies done by the surgeon before a patient surgery. Multivariate survival time regression models were used to evaluate the association between surgeon experience and biochemical recurrence separately in each preoperative risk group. RESULTS: We saw no evidence that patient risk affected the learning curve. There was a statistically significant association between biochemical recurrence and surgeon experience on all analyses. The absolute risk difference in a patient receiving treatment from a surgeon with 10 vs 250 prior radical prostatectomies was 6.6% (95% CI 3.4-10.3), 12.0% (95% CI 6.9-18.2) and 9.7% (95% CI 1.2-18.2) in patients at low, medium and high preoperative risk. Recurrence-free probability in patients with low risk disease approached 100% for the most experienced surgeons.

CONCLUSIONS: Cancer control after radical prostatectomy improves with increasing surgeon experience irrespective of patient risk. Excellent rates of cancer control in patients with low risk disease treated by the most experienced surgeons suggest that the primary reason that recurrence develops in such patients is inadequate surgical technique. The results have significant implications for clinical care.

PMID: 18423716 [PubMed - indexed for MEDLINE]

Publication Types, MeSH Terms, Grant Support

I also had the JH paper.

Hope this partially answers your question.
65 Dx June-2010 PSA: 10.7, biopsy: Adenocarcinoma, 1 core Gleason 6, 3 cores atypia; Clinical stage T2; CT, Bone Scan, MRI all negative

8-23-10 Robotic RP; Pathology: Negative margins; Lymph nodes, Seminal Vesicle clear; PNI present; multiple Adenocarcinoma sites Gleason 3+3 with tertiary Gleason grade 4. Stage: pT2,N0,Mx,R0

Catheter out 8-30-10 no incontinence, no ED. Jan PSA: <.1

Sleepless09
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Date Joined Jul 2009
Total Posts : 1267
   Posted 1/16/2011 10:34 PM (GMT -6)   
clocknut, I don't mind a high bar when it comes to picking a surgeon. My concern is that the number of surgeries bar be recognized for what it is, an interesting number, but not one you'd want to make the primary, or even significant one, to pick a surgeon on.

Sheldon AKA Sleepless
Age 67 in Apil '09 at news of 4 of 12 cores positive T2B and Gleason 3 + 3 and 5% to 25% PSA 1.5
Re-read of slides in June said Gleason 3 + 4 same four cores 5% to 15%
June 29 daVinci prostatectomy, Dr. Eric Estey, at Royal Alexandra Hospital Edmonton one night stay
From "knock out" to wake up in recovery less than two hours.  Actual surgery 70 minutes
Flew home to Winnipeg on July 3 after 5 nights in Ramada Inn  ---  perfect recovery spot!
Catheter out July 9
Final pathology is 3 + 4 Gleason 7, clear margins, clear nodes, T2C, sugeron says report is "excellent"
 
Oct 1st 09 -- dry at night, during day some stress issues.
Oct 31st padless 24/7 
 
First post op PSA Sept 09  less than 0.02
PSA on Oct 23, 2009 less than 0.02
PSA on Jan 8, 2010  less than 0.02
PSA on April 9, 2010 less than 0.02 
PSA on July 9, 2010 (one year) less than 0.02
  

An38
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Date Joined Mar 2010
Total Posts : 1152
   Posted 1/17/2011 2:51 AM (GMT -6)   
 

I think a minimum number of surgeries under a surgeons belt should be a pre-requisite for those who want an optimal outcome. I don't think anyone would suggest that this is the only factor - you absolutely should not do surgery with someone who has bad results or doesn't inspire you with confidence in their abilities.

Walsh, the creator of the nerve sparing procedure suggested in his book that 300 is the minimum number of surgeries a surgeon should have under his belt.

The study below has come up with this table, as you can see the ideal situation is when the surgeon has done >999 surgeries.

http://jnci.oxfordjournals.org/content/99/15/1171/F1.large.jpg

Regards,
An


The Surgical Learning Curve for Prostate Cancer Control After Radical Prostatectomy
Andrew J. Vickers, Fernando J. Bianco, Angel M. Serio, James A. Eastham, Deborah Schrag, Eric A. Klein, Alwyn M. Reuther, Michael W. Kattan, J. Edson Pontes and Peter T. Scardino


Results The learning curve for prostate cancer recurrence after radical prostatectomy was steep and did not start to plateau until a surgeon had completed approximately 250 prior operations. The predicted probabilities of recurrence at 5 years were 17.9% (95% confidence interval [CI] = 12.1% to 25.6%) for patients treated by surgeons with 10 prior operations and 10.7% (95% CI = 7.1% to 15.9%) for patients treated by surgeons with 250 prior operations (difference = 7.2%, 95% CI = 4.6% to 10.1%; P<.001). This finding was robust to sensitivity analysis; in particular, the results were unaffected if we restricted the sample to patients treated after 1995, when stage migration related to the advent of PSA screening appeared largely complete.
Conclusions As a surgeon's experience increases, cancer control after radical prostatectomy improves, presumably because of improved surgical technique. Further research is needed to examine the specific techniques used by experienced surgeons that are associated with improved outcomes.
Husband's age: 52. Sydney Australia.
Family history: Mat. grandfather died of PC at 72. Mat. uncle died of PC at 60. He has hereditary PC.
PSA: Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA 27%)|Feb10 - 4.03 (free PSA 31%) |Jun10 - 2.69. DRE normal.
Biopsy 28Apr10: negative for a diagnosis of PC however 3 focal ASAPs “atypical, suspicious but not diagnostic” for PC. Review of biopsy by experienced pathologist, 1/12 core: 10% 3+3 (left transitional), 1/12 core: ASAP (left apex)
Nerve sparing RP, 20Aug10 with Dr Stricker. Post-op path: 3+4 (ISUP 2005). Neg (margins, seminal vesicles, extraprostatic extension). Multifocal, with main involvement in the fibro-muscular zone. T2C.
Post RP PSA,
Lab 1: Sep10 – 0.02|Nov10 – 0.03|Dec10 – 0.03
Lab 2: Nov 10 - 0.01|Dec10 – 0.01

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4271
   Posted 1/17/2011 10:16 AM (GMT -6)   
An, as usual, says it well.  I don't recall anyone ever saying that number of surgeries is the ONLY criteria for selection of a surgeon.  But I think it's pretty clear that experience is usually a very important criteria.  There are other things that need to be considered as many have pointed out.  And, there are obviously going to be times that the doctor who performs his first robotic surgery is going to perform it well.
 
But...if we are all about giving sound advice to our newly diagnosed friends, I personally think it is incumbant upon us to tell them that one of the ways to get better odds of success in their procedure is to select an experienced surgeon.  That does not mean 50; it means 250+ IMHO.
 
Tudpock (Jim)
 
Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 12/8/10. PSA: 6 mo 1.4, 1 yr. 1.0, 2 yr. .8. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1305643

John T
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Date Joined Nov 2008
Total Posts : 4268
   Posted 1/17/2011 11:20 AM (GMT -6)   
Why would anyone ever consider the 2nd best when the best is available? There are many professions in which the difference between the average and the best is very significant. This is especially true when you are dealing with doctors and lawyers.
65 years old, rising psa for 10 years from 4 to 40; 12 biopsies and MRIS all negative. Oct 2009 DXed with G6 <5%. Color Doppler biopsy found 2.5 cm G4+3. Combidex clear. Seeds and IMRT, no side affects and psa .1 at 1.5 years.

Casey59
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Date Joined Sep 2009
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   Posted 1/17/2011 11:47 AM (GMT -6)   

The cancer treatment centers identified as a Comprehensive Cancer Center (CCC) are found on a "sticky" at this site...go HERE and scroll about 90% of the way down the page.

 

What added value is there is choosing a Comprehensive Cancer Center (CCC), or an expert dedicated to prostate cancer (in our case, for example) treatments in private practice? 

 

While the US indeed has some of the best cancer care in the world, there are clear disparities in cancer diagnosis and treatments documented in a report last year between the top cancer centers and the community settings (local hospitals and generalists in private practice).  [Note that this report was not prostate cancer-specific; it addressed all cancers, but some prostate cancer examples were given.]  First, in order to tee-up the heart of the comparison, consider the two opposite ends of the spectrum:

 

On the one end of the spectrum, some tumors are so non-threatening and their treatment so standard, that it shouldn’t (and doesn’t) matter where you go…your chances are pretty good either way.  For common cancers such as prostate, breast, and colon, the surgery can be very well done in non-CCC settings and the survival rates are comparable to those at the elite cancer centers.  Five years after the nine most common cancer surgeries, the study reported 62% of the patients treated at the CCC centers were alive, compared to 58% at the community hospitals…a difference, but not a huge difference. 

 

On the other end, against some cancers, even the top medical wizards are helpless.  Ted Kennedy’s case of glioblastoma was referenced; he lived 15 months after his diagnosis despite treatment at the Duke University CCC, just slightly over the median survival period.

 

 

What about the millions of cancers cases in the middle—those that are neither hopeless nor straightforward (or as straightforward as cancer can be)?  Here is where differences in outcomes based on where you are treated were most noteworthy.  Fox Chase Cancer Center (in Philadelphia, a CCC facility) provided this data, for example, on the five-year survival of stage-4 prostate cancer patients which highlights the differences:  71% at Fox Chase versus 38% nationwide average.

 

The quality-of-care differences found in the study were, interestingly, not related to who has the newest, coolest multi-million dollar machine, in which case one could forgive small community hospitals for lagging behind.  Instead, it comes down to such basics as experience; to getting the correct diagnosis; to whether doctors address holistic aspects of diet, exercise, and psychological health; to whether doctors routinely test tumors for molecular markers that can guide therapy; to whether multi-disciplinary care is coordinated or haphazard; to how well doctors monitor patients (after surgery, radiation, or chemical treatment) in order to minimize the chance that the cancer will recur.  Examples were provided in the report, three of which I will bullet here:

 

·         Prostate cancer patients already know the importance of expert biopsy pathology readings.  The physician-in-chief at MD Anderson (CCC site) estimated that patients traveling to Anderson have an incorrect diagnosis from a community pathologist about 5 to 10 percent of the time.  Clinically important diagnostic errors can lead to improper or incomplete treatment.  From my personal experience, although I had an initial biopsy reading from Bostwick (known expertise in prostate pathology), when I moved from my local urology generalist who diagnosed me to a CCC my slides were re-read for confirmation at the CCC pathology lab.

·         Another rule that we prostate patients also already know about surgery is to select experienced surgeons.  Outcomes for complex surgeries have significantly disparities between top cancer centers and community hospital settings.  For tough surgeries, you want the doctor who’s been around the block, so to speak; surgeons at the top centers have generally sharpened their teeth elsewhere first.  Furthermore, length of stay and rate of surgical complications are lower at the top centers versus community settings.

·         It was interesting (to me, this was one of the most interesting aspects) how the report characterized a general difference between the approaches of oncologists in the two settings.  Doctors in the community setting (generally) report that there is a lot of art in the treatment of cancer, whereas oncologists at top centers say it’s a science.  “Art” might sound desirable and even personal—my oncologist isn’t blindly following a recipe in treating me!—but it covers a lot of sins, notably the tendency of some doctors to pick treatments that worked for other patients, even though those results might have been statistical flukes.  The “recipes” are well established (see the link to the NCCN Clinican's Guidelines for Prostate Cancer in the original posting) by the National Comprehensive Cancer Network (NCCN). 

 

The third bullet (above) notwithstanding, the top cancer centers were also found to have a much stronger ethic of trying anything and everything when cases turn desperate.  The report highlights that this aspect does not show up in five-year survival data, but can make a huge difference to a patient who gets to celebrate one more wedding anniversary or the birth of a grandchild.

 

 

After this report was published last year, the National Cancer Institute (NCI) launched a quality improvement program to help raise the bar at the community cancer center programs.  Here’s a link outlining the program:  http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2764567/

 

The Association of Community Cancer Centers (ACCC) has also responded (following “encouragement” by the federal government, insurance providers, and medical specialty societies) with a training & education program directed at improving adherence to Clinical Practice Guidelines.  See here:  http://accc-cancer.org/education/education-guidelines.asp

 

 

Now, fellow HW participants, when your friend tells you they have been newly diagnosed with cancer, you can now point out that while the local community hospital might go a great job of making them feel welcomed and well “cared for”, and they will probably have good results, you now understand why they should consider one of the NCI-designated Comprehensive Cancer Centers for the best possible results.

 

Can good care be found outside of the CCCs [i.e., in community hospital settings or at private generalists]?  Absolutely.  Will there be people who feel that they had unfavorable experiences at these centers [the CCCs]?  Absolutely.  But taking the broad view, these centers [the CCCs and the private expert specialists] would absolutely be considered the cream of the crop.

As JohnT indicated (slight re-phrasing by me)...in medical care, one should strongly consider going for the best possible care.


clocknut
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Date Joined Sep 2010
Total Posts : 2679
   Posted 1/17/2011 3:40 PM (GMT -6)   

I' would never argue against finding the best surgeon available to us, and the best setting in which to have the surgery performed.

Nor does it surprise me that there would be disparities between our nation's top cancer centers and local hospitals staffed with "generalists in private practice."  I would certainly expect trained oncologists and board certified uro/surgeons to achieve better results than a "generalist" in private practice."  I understand that to mean they're comparing specialists to GP's or family practitioners (am I wrong?)  It's amazing to me that only two of Chicago's fine hospitals are included on the list of CCC's, and they really aren't the "big name" facilities.

I still think, however, that when we tell a newcomer here, a worried guy scheduled for surgery in just 8 days, that he should reconsider his choice of surgeon....who happens to be a well respected guy with 350 open surgeries under his belt and 150 DaVincis procedures, that we've created problems for him rather than solving the problem that is troubling him.

"Robs" seems like a guy who obviously has done his homework, who has chosen a surgeon with great care and deliberation, who's aware of his heightened risks as a Gleason 8, and whose main concern, as I recall, involved his impending and unanticipated loss of both nerve bundles.  How have we helped him by bringing into question everything he has so carefully arranged for his treatment? 

I think the correct answer is "Good job, Rob.  You seem to have found a good surgeon...one who is upfront about the likely need to take both nerve bundles in order to try to save your life over the long haul."  As a Gleason 8, you want to be sure everything possible is done to prevent a recurrence.  There may be surgeons out there who have done several hundred more surgeries than the guy you've chosen, but his experience in both open surgeries and in the DaVinci robotic technique should work out well for you.  Good luck, and let us know how things turn out.


Casey59
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Date Joined Sep 2009
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   Posted 1/17/2011 4:12 PM (GMT -6)   
clocknut said...

Nor does it surprise me that there would be disparities between our nation's top cancer centers and local hospitals staffed with "generalists in private practice."  I would certainly expect trained oncologists and board certified uro/surgeons to achieve better results than a "generalist" in private practice."  I understand that to mean they're comparing specialists to GP's or family practitioners (am I wrong?) 


No, you misunderstood.  The comparison was like-for-like.

 

The facilities identified as CCCs are the top quality facilities specifically focused on cancer treatment, not other ailements.  "CCC" is a designation by the National Cancer Institute.  USNews also ranks Univ of Chicago (#15) and Northwestern (#27) as the top cancer treatment centers in the region based on their list.  LINK    If I wanted orthopedic work done in Chicago, I would (and I did) go to Rush; cancer, to one of the CCCs.

 

I agree, by the way, with the key point of not trying to place seeds of doubt 8-days before a patient's scheduled operation.


An38
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   Posted 1/17/2011 6:08 PM (GMT -6)   
Robs came in, first post, we do not know what his background is, what specialists he has seen and whether he has a second expert opinion on his slides, all things we recommend to newcomers because the first instinct for all of us is to take the prostate out before fully understanding their status or treatment options. He had only been diagnosed in mid December and is having his surgery in late January.

I think it would be remiss of us not to highlight the issues above and ask him to look at other surgeons and other treatment options. We personally loved the fact that people here questioned our decision to have surgery and urged us to consider other options. The surgery can only happen once and I would think that it would be better to give yourself more than the absolute minimum of 6 weeks post biopsy and postpone your surgery by a month, giving you time to recheck your data and reconsider your options. In a month from the time you are diagnosed you barely have time to get over the initial shock and and within this short timeframe I imagine people generally only look at one treatment option and visit only one surgeon.

There may be a “correct” way to respond to posts but I think to be supportive we have to put ourselves into this man’s shoes and consider what we have learnt in our own journey. I think about how scared we were a month after being diagnosed and how we were not thinking really logically. Of course we would support Robs in whatever decision he chose but I disagree with the approach that because he is 8 days out of surgery that his plans are set in stone and that we cannot provide him some alternative ways to deal with his situation.

An
Husband's age: 52. Sydney Australia.
Family history: Mat. grandfather died of PC at 72. Mat. uncle died of PC at 60. He has hereditary PC.
PSA: Aug07 - 2.5|Feb08 - 1.7|Oct09 - 3.67 (free PSA 27%)|Feb10 - 4.03 (free PSA 31%) |Jun10 - 2.69. DRE normal.
Biopsy 28Apr10: negative for a diagnosis of PC however 3 focal ASAPs “atypical, suspicious but not diagnostic” for PC. Review of biopsy by experienced pathologist, 1/12 core: 10% 3+3 (left transitional), 1/12 core: ASAP (left apex)
Nerve sparing RP, 20Aug10 with Dr Stricker. Post-op path: 3+4 (ISUP 2005). Neg (margins, seminal vesicles, extraprostatic extension). Multifocal, with main involvement in the fibro-muscular zone. T2C.
Post RP PSA,
Lab 1: Sep10 – 0.02|Nov10 – 0.03|Dec10 – 0.03
Lab 2: Nov 10 - 0.01|Dec10 – 0.01

Tudpock18
Forum Moderator


Date Joined Sep 2008
Total Posts : 4271
   Posted 1/17/2011 7:02 PM (GMT -6)   
I absolutely agree with An on this.  If our only role is to say, "Great decision, good luck" then why bother?  Anyone can hear that from his doctor.  Our real value added, besides being supportive, is to help educate men and their families so they can make informed decisions.  Providing comments 8 days before the procedure is a heck of a lot better than 8 days after, IMHO.
 
Tudpock (Jim)
Age 62 (64 now), G 3 + 4 = 7, T1C, PSA 4.2, 2/16 cancerous, 27cc. Brachytherapy 12/9/08. 73 Iodine-125 seeds. Procedure went great, catheter out before I went home, only minor discomfort. Everything continues to function normally as of 12/8/10. PSA: 6 mo 1.4, 1 yr. 1.0, 2 yr. .8. My docs are "delighted"! My journey:
http://www.healingwell.com/community/default.aspx?f=35&m=1305643&g=1305643#m1305643

Casey59
Veteran Member


Date Joined Sep 2009
Total Posts : 3172
   Posted 1/17/2011 7:10 PM (GMT -6)   
Point well taken, Tud and An.

What if it was the day before surgery? Two days? At some point, it seems counter-supportive.
 
[My question here is purely rhetorical...for discussion only.  I don't know the answer on this one.]

goodlife
Veteran Member


Date Joined May 2009
Total Posts : 2692
   Posted 1/17/2011 10:32 PM (GMT -6)   
If you ever were to bet on a golf match, would you bet on Tiger Woods or the local golf pro ?

It only stands to reason that the more surgeries a dr does, the more proficient he becomes.

However, there is the raw ability vs experience. Many golfers will play all of their lives and never be nearly as good as Tiger was his first year in the pros.
Goodlife
 
Age 58, PSA 4.47 Biopsy - 2/12 cores , Gleason 4 + 5 = 9
Da Vinci, Cleveland Clinic  4/14/09   Nerves spared, but carved up a little.
0/23 lymph nodes involved  pT3a NO MX
Catheter and 2 stints in ureters for 2 weeks .
Neg Margins, bladder neck negative
Living the Good Life, cancer free  6 week PSA  <.03
3 month PSA <.01 (different lab)
5 month PSA <.03 (undetectable)
6 Month PSA <.01
1 pad a day, no progress on ED.  Trimix injection
No pads, 1/1/10,  9 month PSA < .01
1 year psa (364 days) .01
15 month PSA <.01

Postop
Regular Member


Date Joined Feb 2010
Total Posts : 385
   Posted 1/17/2011 10:55 PM (GMT -6)   
Hopefully your doc will have Tiger's skill, but also better judgment that he does. A surgeon needs both.

Sleepless09
Veteran Member


Date Joined Jul 2009
Total Posts : 1267
   Posted 1/18/2011 9:49 AM (GMT -6)   
Goodlife asks: "If you ever were to bet on a golf match, would you bet on Tiger Woods or the local golf pro ?"

I'd be going with Tiger. But, if we were at a PGA this week and I was betting on who would finish first, Tiger or one of the other golfer's, I'd not be paying much attention to how many games they'd played in their career. No doubt the number of games, and even the number of times they've played a particular course, is a factor, but there are other more important critical factors to consider. So too with surgeons.

Unfortunately for the most part all we have as patients to go on with surgeons is generally somewhat broad brush stroke information such as number of surgeries. I doubt very much when a PCa surgeon needs an RP that they're basing their decision on whose table to lie down on, on simply number done. It won't be a first time surgeon, but after the number is somewhere north of 50 I suspect other factors (average length of surgery, post surgical complication rates, blood loss, cool head in a crisis among them) take over. This is information a doctor can find out about, some documented, some word of mouth from respected sources. It is information that is difficult and sometimes impossible for non-medical patients to access, and so we are left with seeing in a glass darkly and making do with what we have.

There is no easy solution for a non-medical person to get the information we'd all like to have. But I always encourage new PCa people (and isn't it amazing how many phone calls you get from guys who have just got the news) to think about the sort of criteria their doctor would use in deciding on a treatment, or a treatment person, and then using whatever networking they can to find the answers.

It is amazing how connected we all are once you begin to dig into networking. While it may be six degrees between anyone and someone else, often it is just one or two.

An, others in this thread, thank you for your thoughts. All interesting and helpful. A great thread. In the end all any of us want for ourselves, our loved ones, our friends, is the best shot. Figuring out how to get it is important stuff.

Sheldon AKA Sleepless
Age 67 in Apil '09 at news of 4 of 12 cores positive T2B and Gleason 3 + 3 and 5% to 25% PSA 1.5
Re-read of slides in June said Gleason 3 + 4 same four cores 5% to 15%
June 29 daVinci prostatectomy, Dr. Eric Estey, at Royal Alexandra Hospital Edmonton one night stay
From "knock out" to wake up in recovery less than two hours.  Actual surgery 70 minutes
Flew home to Winnipeg on July 3 after 5 nights in Ramada Inn  ---  perfect recovery spot!
Catheter out July 9
Final pathology is 3 + 4 Gleason 7, clear margins, clear nodes, T2C, sugeron says report is "excellent"
 
Oct 1st 09 -- dry at night, during day some stress issues.
Oct 31st padless 24/7 
 
First post op PSA Sept 09  less than 0.02
PSA on Oct 23, 2009 less than 0.02
PSA on Jan 8, 2010  less than 0.02
PSA on April 9, 2010 less than 0.02 
PSA on July 9, 2010 (one year) less than 0.02
  

clocknut
Veteran Member


Date Joined Sep 2010
Total Posts : 2679
   Posted 1/18/2011 10:26 AM (GMT -6)   
Sleepless, that's a great post!  And you're right...this thread has some great thoughts and comments by An, Casey, Goodlife, Tudpock, and others.
 
This topic is dear to me because my own surgeon, as I've mentioned previously, has only done about 50 DaVinci's (though he's done God knows how many open surgeries).  Yet, I've heard his praises sung by family docs, cardiologists, a neurosurgeon, an O. R. tech, nursing staff, and many others.  A local doctor who needed a prostatectomy chose my surgeon, even though here in the Chicago area he could easily have chosen any one of dozens of other surgeons at major cancer centers in the Chicago area.  Every time I mention this uro/surgeon's name, the auto response is, "Oh, he's good!"
 
I don't mean to underestimate the importance of experience, but some talent emerges early, or as in the case of my surgeon, the DaVinci skills are built on top of many years of solid experience in urology and open surgery.  My wife is an R.N., and assures me that nurses and O. R. techs know who shows skill in the O. R., whose patients do well, who is cool and competent under pressure, who knows when they're getting in over their head and is willing to call in the cavalry, who can transition from DaVinci to open surgery should the need unexpectedly arise.  My R.N. niece (in New York) is a surgical nurse.  She was telling me at Thanksgiving how the different talent levels among surgeons is pretty obvious in the operating theater, and it doesn't necessarily relate to the number of surgeries the individual has performed.
 
I don't think any of us disagree on the fact that anyone scheduling a prostatectomy should place surgical competency at the top of their hierarchy of needs.  I just strongly disagree that the requirement for 500 or 1000 surgeries should be the first item on their check-off sheet.  I think this has been a good discussion with a wide variety of opinions on an important topic.
 
 
 
 

142
Forum Moderator


Date Joined Jan 2010
Total Posts : 7078
   Posted 1/18/2011 11:20 AM (GMT -6)   
I had to go to two different hospitals for tests, where my surgeon practices as well. I asked at the volunteer desks about him, and they found some of the long-time volunteers for me to talk to. In both cases the reports were very good (one male volunteer had been an open RP patient of my surgeon some years ago).
 
Also got some feedback from men who had been treated at other facilities.
 
Just another source of grass-roots information.
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