August 3, 2007
American Cancer Society

Experience Counts for Prostate Surgery Success

Fewer Recurrences When Surgery Done By Seasoned Doctors

Men who need surgery for prostate cancer should seek out a surgeon with a lot of experience, a new study suggests. Researchers from 3 major cancer centers have found that men treated by seasoned surgeons are much less likely to have a recurrence of their prostate cancer than those operated on by less experienced doctors.

It's not exactly surprising that more experienced surgeons get better results, says lead study author Andrew Vickers, PhD, but the impact hasn't ever been measured in this way before for prostate cancer, and the difference is striking. Vickers and his colleagues calculated that a man operated on by a surgeon who has performed 250 or more prostatectomies has an absolute risk of recurrence 5 years after surgery that is 7.2% lower than one treated by a surgeon who has performed 10 or fewer procedures.

"If you had a drug that led to 7 fewer recurrences per 100 patients, that would be astounding," says Vickers, who is associate attending research methodologist at Memorial Sloan-Kettering Cancer Center in New York. "This is a huge difference between the inexperienced surgeon and the experienced surgeon."

The findings are based on 7,765 men treated by one of 72 surgeons between 1987 and 2003. The surgeons were from 4 institutions: Memorial Sloan-Kettering Cancer Center in New York, Baylor College of Medicine in Houston, Wayne State University in Detroit, and the Cleveland Clinic in Cleveland, Ohio. Surgery was the only treatment the men received; none got any type of radiation, hormone therapy, or chemotherapy.

Steep Learning Curve

Vickers and his colleagues analyzed the number of prostatectomies the surgeons had performed over the course of their careers and prostate cancer recurrences in the study patients. Recurrence was determined by looking at levels of PSA (prostate-specific antigen) in the men after surgery. Once the prostate is removed, PSA should be virtually undetectable. If levels start to go up again, it's a sign that some cancer cells may still be present, Vickers says.

"The surgeon has to remove the tumor and not leave any microscopic traces because those traces will be picked up by a very sensitive chemical [test] later," he explains.

Because surgery was the only treatment, he adds, "we think we're really able to identify an effect on patient outcome of differing surgical techniques." If the men had received other treatments in addition to surgery, it would have been difficult to tease out and quantify the individual effects of each treatment.

There were 1,256 recurrences among the patients during an average of about 4 years of follow up.

Using this information, Vickers and his colleagues calculated the men's chances of having a recurrence within 5 years. Men treated by a surgeon who had performed 10 or fewer prostatectomies had about a 17.9% chance of having the cancer return, while those treated by a surgeon with 250 prior operations had a 10.7% chance of relapse. This difference remained even after the researchers controlled for possible differences in the types of patients the surgeons treated (those with more advanced tumors vs. early-stage ones), the year the surgery was performed (to account for the impact of widespread PSA testing, which finds more early tumors), and how aggressive the tumor was.

The likelihood of a patient remaining cancer-free increased steadily and sharply as surgeons performed more prostatectomies, leveling off at 250 procedures.

"What we've shown is that if you're only doing 3 prostatectomies a year, you're not going to get as good as you could be [at performing the operation]," Vickers says.

Choose a Surgeon Carefully

All this means men need to do their homework when choosing a doctor to treat them for prostate cancer. Surgeons at specialized cancer hospitals are more likely to have more experience, Vickers says. Previous studies have shown that urologists who work outside of such settings -- in private practice, for instance -- often perform only a handful of prostatectomies each year.

But patients still need to ask questions of their doctors. Most of the surgeons in this study (57%) had performed fewer than 50 procedures, even though all were working at large academic hospitals.

The findings also raise questions about the best way to structure prostate cancer care, Vickers says. Perhaps more men would have better outcomes if more prostate cancer cases were handled by doctors and hospitals that specialize in treating the disease.

Likewise, outcomes might improve if surgeons received ongoing training to help them perfect their technique. That might take the form of hands-on continuing education courses, or mentoring programs.

But in order for such programs to be effective, researchers first need to figure out exactly which surgical techniques give the best results. Vickers says his group is trying to design clinical trials comparing different surgical techniques, much the way other studies compare different chemotherapy regimens for other types of cancer.