Outcomes for Radical Prostatectomy: Is It the Singer, the Song, or Both?

VOLUME NUMBER FEBRUARY J OURNAL OF C LINICAL O NCOLOGY COMMENTS AND CONTROVERSIES Outcomes for Radical Prostatectomy: Is It the Singer, the Song, or Both? Matthew R. Cooperberg, Anobel Y. Odisho, and Peter R. Carroll, University of California, San Francisco Helen Diller Comprehensive Cancer Center, San Francisco, CA See accompanying article on page 513 Radical prostatectomy is one of the many treatment options available to men with clinically localized prostate cancer, and it may be the preferred option for some on the basis of cancer risk and patient age, comorbidity, and preferences. 1 The procedure is associated with excellent cancer control rates. Overall prostate cancer–specific sur- vival at 15 years after prostatectomy has been shown to be approxi- mately 93%; even for those with advanced stage (T3, N⫹) and/or high-grade disease (Gleason grade 8-10), that figure is 63% to 74%. 2 Radical prostatectomy is the most highly used treatment for prostate cancer, with approximately 40% to 50% of men selecting this treat- ment initially. 3 The procedure can be performed by using various approaches, including retropubic, perineal and laparoscopic ap- proaches. Laparoscopic prostatectomy can be facilitated by using ro- bot assistance. Until recently, the vast majority of prostatectomies were performed using the open, retropubic approach, whereas the past decade has witnessed a rapid uptake of robot-assisted radical prostatectomy (RARP) nationwide. The robot is impressive technology, allowing the surgeon to sit at a console and direct a camera and two or three laparoscopic arms with six degrees of wristed motion for cutting, retracting, cauterizing, or suturing—all with high magnification and three-dimensional visual- ization. However, technology that is rapidly adopted should have clear benefits—increased effectiveness, less morbidity, more accessibility, and/or decreased cost. Many argue that the increased use of robotic technology may not be primarily driven by such benefits but rather by heavy marketing, whether by the company that produces the technol- ogy, by hospitals that have acquired it (at high cost), or by physicians who promote it to gain market share. Hospitals that acquire a robot appear to have the largest increases in surgical volume. 4,5 Indeed, a review of hospital Web sites demonstrates a mix of manufacturer and hospital claims of superior outcomes for robot-assisted surgery, with- out disclaimers regarding the limitations of existing outcomes data. 6 The problem of potentially misleading marketing is by no means unique to robot-assisted surgery; similar marginally founded claims are frequently made about other treatments as well. Although the number of prostatectomies performed has in- creased, the location and costs of installed robotic systems has central- ized care. Whereas outcomes may be improved, centralization leads to decreased access resulting from longer travel times, which dispropor- tionately affect patients with limited financial means. 7 RARP also tends to be more costly; on average, robotic surgery adds approx- © 2012 by American Society of Clinical Oncology imately $2,200 (20%) to the cost of a prostatectomy as a result of increased supply costs and operating room time. 8,9 To be fair, though, these costs should also be compared with those of other treatment alternatives, such as intensity modulated radiation (IMRT) or proton-beam therapy, whose costs— both capital and marginal—are far greater. 10 If more efficient care, increased access, and lower costs are not driving the greater use of robotic surgery, then what is? There is no question that RARP is associated with less blood loss, lower transfu- sion rates, and slightly faster convalescence. 11,12 It appears to be essen- tially equivalent to open surgery in terms of cancer control rates. 13,14 The critical question, however, is whether RARP compares favorably with open surgery in terms of patient-centered health-related quality-of-life outcomes. In the article that accompanies this edi- torial, Barry et al 15 are the latest to suggest that it may not. Using a population of patients drawn from a 20% Medicare sample, the authors assessed urinary and sexual bother after open prostatec- tomy and RARP, reporting a nonsignificant trend toward greater urinary bother and equivalent sexual bother after RARP compared with open prostatectomy. Although methodologically much more sound than an earlier analysis that tried to determine health-related quality-of-life outcomes on the basis of claims data alone, 16 the study by Barry et al 15 still has significant limitations, many of which are acknowledged by the au- thors. Given the use of a Medicare data set, all patients were 65 years of age or older. All operations were performed in 2008, when many surgeons may have been climbing the RARP learning curve. There was no baseline functional assessment, and as the authors note, the two groups may not been comparable in that respect. Results are further clouded by the authors’ use of a brief, dichotomized instrument that assessed only bother rather than both function and bother using a standardized, validated instrument such as the Prostate Cancer Index (PCI) 17 or the Expanded Prostate Cancer Index Composite (EPIC). 18 Patient perception of bother is clearly a key outcome of interest and may associate best with use for health outcome states. However, bother does not correlate perfectly with functional outcomes 19 and may also reflect baseline function and pretreatment expectations. Whether resulting from misleading advertising or counseling or sim- ply from misplaced faith in technology, men opting for RARP tend to have higher expectations than those undergoing open surgery and Journal of Clinical Oncology, Vol 30, No 5 (February 10), 2012: pp 476-478 Information downloaded from jco.ascopubs.org and provided by at CONS CALIFORNIA DIG LIB on July 20, 2016 from Copyright © 2012 American Society of Clinical Oncology. All rights reserved.