Men with High Gleason Score Prostate Cancer should be given honest appraisals and expectations of outcomes from treatment

Men with a Gleason score 8-10 cancers have a significant chance of not being cured by radical prostatectomy.  Only in very exceptional circumstances would a man with a Gleason score 8-10 cancer be offered surgery if extent of disease scans (typically scans such as a bone scan and CT scan of the abdomen and pelvis) show evidence of spread to other organs.  

The vast majority of men with Gleason score 8-10 prostate cancer are offered surgery because there is no objective sign of cancer spread on scans and provided other factors such as age and concurrent medical problems are not likely to be an issue.  The big BUT is that if such scans fail to show signs of spread, it does not mean that spread has not occurred.  We know for a significant number (at least 30-50%) will have already had microscopic spread that is simply beyond the resolution of the scans to detect.  In other words, let’s say that some cancer cells from the prostate gland have managed to enter into blood vessels or lymphatic vessels and travel all the way to either the bones or lymph glands respectively. Remember that tiny deposits less than a millimetre is size would have no chance of being seen by a scan.  Before operating on such men, we need to be honest with them about this possibility.  They need to recognise that even if we are to successfully remove the prostate and have the prostate specimen margins free of cancer, it does not mean that they have necessarily been cured.  It is simply one of a number of hurdles that have been jumped over.

Having a Gleason score 8-10 prostate cancer is bad enought but if we look at men who have Gleason score 10 cancer in particular, we would regard these men as having a very high (not just high) risk of existing microscopic spread.  When these men undergo radical prostatectomy, a typical expectation is that less than 40% will be alive in 10 years without having signs of detectable spread of the cancer.  Even fewer will be alive with signs of cancer having returned as evidenced by their PSA blood test levels. In other words, most men with Gleason score 10 cancer will not be able to be cured.  This of course does not mean that these men should not be offered treatment with curative intent but it is an indication that appropriate counselling be offered and that men not be given false expectations about their prognosis.  It would be brave to suggest to such men that after surgery for a Gleason score 10 cancer, that they had ‘beaten it’ just because the surgical specimen showed that the excision margins did not have cancer at the edges (also known as positive surgical margins).  Another consideration is that these men who have arguable the worst prognosis, should be offered the opportunity to participate in clinical trials give them access to additional promising treatments that could offer them the best hope of overcoming these cancers. In my opinion, this is less likely to be offered in the setting of treatment by commercially driven surgeons.

There is more to treatment decision making processes than what the Gleason score is found to be on prostate biopsies. This blog piece attempts to show just one aspect of how we consider how we embark upon offering the best for our patients. 

The intention was not to make this blog piece sound like an argument against offering men with the most aggressive prostate cancers any treatment.  I regularly offer men with clinically localised 'high risk' prostate cancer treatment with curative intent.  In spite of our recognition that many will experience signs of failure to cure the disease, treatment offers these men their best chance.  Recent randomised control trial data shows that there is increasing evidence that treatment for this particular group of men makes a clinically relevant impact upon their survival.   

On a final note, I draw attention to a tweet from Dr David Samadi who is a 'celebrity' urologist who claims cure rates of 97% from prostate cancer surgery - he indicates that he has a patient who had just recently undergone surgery who had now ‘beaten the disease’ and is celebrating. You make up your own mind whether the patient has been given realist expectations on what the future holds for his cancer.  When the PSA starts rising, will Dr Samadi look after him now that the surgery is done, or simply refer him to another specialist (medical or radiation oncologist) to manage something that is no longer for him to look after? I do not know the answers to these questions but leave it in your mind to decide.

Update on Transitioning From Open to Robotic Assisted Radical Prostatectomy

Since I first blogged on robotic surgery in July last year, it has become the predominant manner by which I perform prostate cancer surgery.  I continue to offer open surgery and particularly for those who cannot afford the cost of robotic surgery - it is important to not make them feel inadequate and that there is a reasonable alternative approach available.  Robotic surgery for prostate cancer is rapidly moving towards being the predominant manner by which prostate cancer surgery is being performed in Australia.  

Sydney had the lowest concentration of robotic platforms per capita in any of the mainland capital cities and for many years there was only one hospital with the technology.  Subsequent to a second hospital acquiring the technology and the significant marketing that followed, the dominos fell rapidly.  In the space of less than two years, there are now 7 hospitals in Sydney which now gives it the highest concentration of robotic platforms in Australia.  The competition for men to undergo robotic assisted radical prostatectomy has never been more palpable.  Many surgeons feel they are being forced into the technology on the basis of marketing pressures rather than being able to transition into the technology on their own terms. There has been a sense of urgency for surgeons to enter into the robotics space and enthusiastically offer their services and there is this sense of urgency for surgeons to announce that they have reached a certain threshold of cases or are now the most experienced with the technology for a particular geographical part of Sydney.  The tenor of competitive marketing material has lowered to include accusations of how one hospital is much more expensive than another without any factual basis to make such statements.  

One surgeon's overzealous attempts to market his services went to the extremes of misleading readers of his training credentials and true level of experience.  His marketing was excessive to the extreme that he has been formally counselled by his university and reprimanded by our professional body, the Urological Society of Australia and New Zealand.  He has also been referred to the Royal Australasian College of Surgeons for investigation of breach of its Code of Practice and to the Australian Health Practitioners Regulatory Authority for investigation of breach of advertising regulations.  Others have provided more carefully crafted glossy brochures to referring general practitioners and it is becoming increasingly common to have the addition of the term "Robotic Surgeon" to their professional stationary.  I hope that I will continue to not have to resort to these measures in order to maintain my existing sub-specialised practice in prostate surgery.  

I digress for just a moment to recount how a mentor of mine once told me when I started practice that the best advertising you could do was to look after your patients well.  In other words, your patients would be your best advertisement. Maybe this is an old fashioned approach but for as long as this still works for me, then I will consider myself fortunate.  That said, back on topic.

I feel very grateful for the fact that I have been in the position to pick and choose which patients that I felt that I could safely offer robotic surgery instead of open surgery in my hands.  This enabled me to get comfortable with doing easier cases before taking on more complex cases.  I am now comfortable with offering robotic assisted radical prostatectomy for all men for whom surgery is an appropriate option.   I have been extremely fortunate to have undergone transitioning to this technology in an era where training tools (such as the virtual reality simulator), an established technique and surgical proctoring were so readily available to me.  I am particularly grateful for my friends and colleagues Damien Bolton (Melbourne) and Peter Swindle  (Brisbane) making an effort to come to Sydney to help train me without accepting any remuneration for my over and above minimum expected proctored cases.

Robotic surgery is clearly here to stay and to be fair, the advantages of  less pain and quicker recovery have turned out to be more profound than what I had anticipated.  It was very easy to be critical of such claims when I had no personal experience with the technology and given that I had thought that my patients undergoing open surgery were doing just fine with no need improve upon this.  It has also been gratifying to see that my cancer clearance rates and recovery of continence are unchanged although I have an impression that the latter is actually better.  It is too early to know for sure of my outcomes for recovery of erectile function but my impression at this early stage is that it may in fact be better.  In spite of great anxiety and trepidation in making this transition, it is pleasing to report that my personal experience with adopting robotic surgery has turned out to be a particularly positive and exciting period of my surgical career.   My only disappointment has been the aggressive marketing and collegial fragmentation seen in association with the rapid uptake of the technology.  As one very astute GP wrote to me regarding a second opinion referral that he had sent to me: "I am concerned that the joy of a new technology and one's desire to expand their series is impacting on clinical decision making" - I sincerely hope that the race to adopt robotic surgery does not become a prostate harvesting exercise after the huge leaps forward that have been made in embracing conservative approaches such as active surveillance for those with clinically insignificant disease.  

Transitioning to Robotic Assisted Surgery

I am a relatively late comer in adopting the robotic assisted surgical approach to radical prostatectomy for prostate cancer. If you look at this piece from the New York Times, you will understand why I have little real choice other than to offer this to my patients (http://www.nytimes.com/2010/02/14/health/14robot.html? _r=1&emc=eta1). The article is now a couple of years old but we were able to resist being forced into this new technology in Sydney, Australia until now. This time last year, there was only one hospital with a Da Vinci robotic system. Having surgery performed at that hospital is expensive and compared to some surgeons fees elsewhere, multiples of times greater. Colleagues in Melbourne, where robotic surgery has long been the norm, have reported that they regularly saw patients from Sydney as a result of the cost of surgery there being significantly less, even allowing for flights and accommodation. When consideriing the maximum numbers of patients that could physically be treated at one hospital in Sydney, the finite numbers of men who were prepared to pay the large costs of such treatment and those prepared to travel interstate, these numbers were never going to threaten the viability of a urologist's prostate cancer practice in a city the size of Sydney. Fast forward to less than 12 months later, we now have 4 hospitals with Da Vinci systems that are up and running with another two hospitals likely to have systems installed by the end of this year. The dominos have well and truly fallen, but it was only a matter of time when the last Australian capital city strong hold of open radical prostatectomy surgery would buckle to the market forces. The acquisition of this technology at my hospital has meant that I have had to undergo intense training to make the transition. I am grateful for the fact that as a later adopter, I have had access to training materials that were not available to colleagues only a few years earlier. In recent years, an excellent surgical simulator has been developed and this has made a huge difference to my transition from open to robotic assisted radical prostatectomy. The need to train for robotic assisted radical prostatectomy seemed perfectly timed. I was due to attend the American Urological Association Annual Meeting in Atlanta and this provided a perfect opportunity to attend various live surgery opportunities at that meeting as well as to attend laboratory training whilst in the USA. At the AUA meeting, I made a point of attending a number of interactive live surgical demonstrations of the surgery being performed as well as attend scientific sessions relevant to the technology. Immediately following the meeting, I took a flight to the San Francisco Bay Area and took the opportunity to attend surgery being performed by the renown Professor Peter Carroll at the University of California San Francisco Medical Center. Apart from seeing the actual surgery, it was instructive to see the dynamics within the operating theatre set up. The next day, I attended the Intuitive headquarters at Sunnyvale where they have a large training facility. It was a full day of intensive training with just myself with one Da Vinci system allocated to me, one professional trainer allocated to me as well as one anaethetised pig upon which the surgery was performed. We were quickly reassured and could see first hand that the pigs were dealt with in a completely humane manner. It has been stated that 9 to 10 hours on the simultor ought to be a minimum amount of time spent on the surgical simulator. After I had done this for 9 to 10 hours, I was regularly achieving 100% scores in the numerous exercises offered by the simulator. when I thought carefully about my own progress, I recognised that my 100% scores were really about me having mastered the technique of getting the simulator computer to tell me that I am doing well. In reality, I certainly had the technical basics mastered but I was far from fluent with my economy of motion and where the operation of both the hand and foot controls felt close to being second nature. On this basis, I pushed on and did over 40 hours on the simulator. I also made a point of spacing out the sessions over a number of weeks and using the time in between to reflect upon my progress. Additional to the simulator, an excellent trainer device has been created. A plastic model the shape and size of a human torso houses a plastic bladder and urethra - this formed an excellent model upon which suturing of the bladder to the urethra could be practised. This stage of training was intentionally left until I had completed the hours that I had determined that I would wish to do, and had I attempted this stage after only say 9 or 10 hours on the simulator, I would not have been able to repeatedly join the model bladder to the urethra with evenly positioned and tensioned sutures. Additional to the above were hours spent doing the on-line training modules created by the manufacturers as well as countless hours watching recorded DVDs of the procedures as well as U-tube videos - this was probably in the order of 40 to 50 hours. As we approached the days on which I would perform my first cases, we did a 'dry run' in the operating room to clarify what went where and who did what. A proctor well experienced in this surgery was organised at my expense to attend my first three cases. It is generally recommended that at least three proctored cases be undertaken but I had decided from the outset that this was inadequate. A period of reflection followed my first three cases associated with further numerous hours watching procedural DVDs. A further two proctored cases were performed and these were also completely successfully performed procedures. These additional two cases gave me significant confidence that I was now ready to commence solo practice with this technology. Having done over 1500 open radical prostatectomy procedures in addition to taking the preparatory training well above the minimum requirements has in my mind made an enormous difference. Having said this, I still do not have the fluency that I enjoy with open surgery, but mainly because I am being overly cautious and prefering to take things slowly and at all times having the patient's safety as the priority over surgical pride in how quickly the procedure can be performed. For now I will continue to offer open surgery but robotic assisted radical prostatectomy is offered to those who desire this technology. The conclusions that I reach from personal experience (and clearly not on the basis of a scientific trial) is that the current minimum requirements before a surgeon can independently perform robot assisted radical prostatectomy should be raised to a much higher level. Nobody gets hurt by doing too many hours on a simulator or doing too many proctored cases. Patients will get hurt in learning curves when shortcuts are taken to get onto the bandwagon. Lets also get rid of the threshold of 20 cases to be officially gazetted as a robotic surgeon - all this does is encourage a race to get to this caseload experience which could be at the detriment of patient safety.