Dr. Scardino Discusses Prostate Cancer Surgery Outcomes: Surgeon Dependent Factors

UroToday.com - Dr. Peter Scardino, Memorial Sloan Kettering Cancer Center gave a presentation on surgeon dependent factors that influence the outcomes for patients undergoing radical prostatectomy. Andrew Victors, the statistician on the project also spoke. In 2002, a study published in the NEJM analyzed the SEER database from 1,000 surgeons and found that 15% of the surgeons did 50% of the cases.

Mortality in the first 30 days was not related to surgeon volume, but complications were. The 15% of high-volume surgeons demonstrated difference in complications that was not dependent on number of cases, suggesting that technique in addition to volume mattered.

The questions presently posed were is surgeon experience associated with biochemical recurrence (BCR) and what is the heterogeneity of surgeon experience. No prior study has evaluated the learning curve in oncologic surgeries. The goal would be to reduce the heterogeneity of surgeons. 9,376 patients undergoing RP at several institutions were studied. The entire surgeons' career cases were included. It tracked the entire career of surgeons', despite institutional moves. Numerous statistical variables were assessed. It accounted for case-mix and other variables. The number of prior cases done by the surgeon before doing an individual's surgery was measured. Subgroup analysis showed superior recurrence free survival for patients treated by surgeons with greater than 1,000 operations compared to <50 operations. After 250 surgeries, the curves plateau. The risk of recurrence decreased from 17% to 10% for surgeons performing 250 surgeries and just 10 surgeries, respectively.

Looking at the chronological history of an individual high-volume surgeon showed the same learning curve at the beginning of their career. Fellowship training followed by an academic practice was significantly associated with superior learning and outcomes. A 34% difference in outcomes was found between surgeons with identical numbers of cases and case complexity, suggesting that surgical technique accounted for this. The implications are that perhaps there should be regionalization of radical prostatectomies to maximize outcomes. Re-evaluation of initial training and ongoing training and feedback are influencing variables.

During Q&A, Dr. Klotz pointed out that in Canadian data after 50 cases there was a slight dip in outcomes suggesting either less surgeon interest or perhaps trainees doing more of the surgery. This was not noted in the Scardino database. In response to another question, the degree to which trainees were involved in the surgeries was not evaluated. Social implications regarding insurance usage of data such as this was raised. To improve techniques, use of videotaping and review by surgeons might improve outcomes.

Report from The Society of Urologic Oncology Winter Meeting - National Institutes of Health - December 1-2, 2006
Reviewed by UroToday.com Contributing Editor Christopher P. Evans, M.D

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