The Greens oppose the CPRS not because it is too weak, but because it will point Australia in the wrong direction with little prospect of turning it around in the timeframe within which emissions must peak, says Senator Christine Milne.
Nerve-sparing surgery for prostate cancer in trouble
|
The prostate cancer debate has taken yet another interesting turn. Just weeks after the Urological Society of Australia urged all Australian men over 40 to get screened, only to have the Royal Australian College of General Practitioners reconfirm its rejection of screening for men of any age. A major new study just published in the Journal of the American Medical Association (JAMA) has thrown another spanner in the works of screening advocates. The big problem with screening lots of asymptomatic men for prostate cancer is that many of the cancers that will be found and surgically removed would not have killed the men, had they been left undetected. We know this from the results of a large nine-year European trial published earlier this year where the prostate cancer death rate in men who were screened were compared with the rate in men who were not screened. If early detection was sensible, you would expect that in the screened group, that there would be fewer deaths from prostate cancer because it had been detected early. The study found that if you screen 1000 men, you will find 82 cases of prostate cancer, and if you follow these men for an average of nine years, there will be 2.94 deaths. In 1000 unscreened men over the same period, 48 cases of prostate cancer will come to light by men presenting symptoms to their doctor. There will be 3.65 deaths. The difference between the two means, in short, that testing saves 0.71 deaths per 1000 men over nine years. But aside from all these men living with the stress of having being told that they have cancer, the surgical procedure (removal of the prostate) that mostly follows diagnosis causes high levels of urinary incontinence and impotence. According to a review last year by the US Preventive Services Taskforce, one year after surgically removing the prostate gland, 20-70% of men have reduced erectile function, and 15-50% have persisting urinary problems. If prostate cancer would not have harmed many of these men — they would have later died from other causes with prostate cancer, but not from it — then this widespread burden of unnecessary surgical side effects is a major downside of the whole push to have men screened. Some surgeons have sought to counter this problem by arguing that modern techniques using precision robotic surgery employing the da Vinci robotic surgery machine produce better surgical outcomes. Melbourne’s Professor Tony Costello is one of Australia’s highest profile prostate surgeons. His personal website states that the benefits of robotic surgery “may include reduced risk of incontinence and impotence”. But then again, they may not. The JAMA study of 1938 men followed for five years reported that, compared to routine “retropubic” radical prostatectomy, minimally invasive prostatectomy performed via robotic surgery “was associated with an increased risk of genitourinary complications (4.7% versus 2.1%) and diagnoses of incontinence (15.9 versus 12.2) and erectile dysfunction (26.8 versus 19.2 per 100 person-years). In other words, the “nerve sparing surgery” being pushed by the handful of surgeons who have invested in it appears to make things worse. The machines cost $2.7m and in the US, robotic systems cost providers about $US1.2m to run a year. Doctors outlaying such investments plainly have a massive incentive to keep up a healthy through-put of patients using the equipment and one of the ways of doing this is to promote the advantages to patients of better surgical outcomes. Dr Philip Stricker, who set up the robotic surgery program at Sydney’s St Vincent’s Hospital and boasts this week in the on-line medical newsletter 6 Minutes of having performed more robotic prostatectomies than anyone else in NSW, was quick to argue that the American results reflect inexperience “it takes time, experience and technique to achieve equal oncological and potency results” and that “many of the surgeons who adopt this perform few surgeries and therefore never get off their learning curve”. So what are Australian men to make of such a statement? Can Dr Stricker or anyone else advise Australian men of the independently audited surgical complication rates he and his colleagues around the country achieve using robotic surgery? Can Australian men receive anything beyond reassurances from their doctors, one eye on their hefty investments in the da Vinci equipment, that they will be in good hands? Simon Chapman is Professor of Public Health at the University of Sydney and NSW Cancer Researcher of the Year 2008 |
|
|
13 Comments
Yes worrying Simon … and good that you give this issue an airing.
But going beyond that, two things are missing from so much of the discussion around this issue - and indeed many other screening processes. First there is considerable anxiety around screening which those keen on screening seem not to take into account in any cost benefit equation.
Second is it not time to investigate more thoroughly the impact of fee for service medicine? Research tells us that paying doctors to do things gets them to do more of these things. To what extent however is policy on FFS based on obtaining optimal, i.e. to this economist efficient levels of treatment? And what about the patients? How can we be sure under FFS that a procedure recommended under FFS would be recommended if the doctor were paid differently?
If we are trying to make our health service more efficient, maybe this is an area for more research.
Even apart from the screening of healthy men issue- how to treat early prostate cancers continues to be of great concern. Do the Urologists as a professional group actually agree how to treat early prostate cancers? If they have agreed guidelines do they follow them and who checks? Are the outcomes measured? (of particular importance in private hospitals/clinics); is data published? And if a urologist specialises in surgery will low or high dose brachytherapy or radiotherapy be discussed as an option? This whole topic lacks transparency and really open discussion - both the issue of screening healthy men and how to treat prostate cancer. GPs know little more than the man in the street…where are the health groups in all this? Where are spokesmen from health departments? Just having this exchange of comments on Crikey is too limited to be of real value to the community as a whole. We’ve had Dr Malouf re-spruiking PSA tests and no-one challenged him publicly from any of the health groups; and now we have the da vinci dimension. Well done Simon Chapman for challenging the vested urological interests but lets hear from the health groups before the sale of incontinence pads goes through the roof!
The statistics seem to say taking a prostate exam isn’t worth it … and it isn’t like it’s some fun experience. I wonder what was behind the naming of the da Vinci robotic surgery machine …
Well presented article Simon but it solves nothing really. The trials mentioned don’t seem to separate age groups which is an important factor. Younger men (say sub 50) often have the more agressive form of prostate cancer (read Wayne Swan) and ignoring the condition will likely kill them at a young age. However, men in the older age group(say 65 plus) are more likely to have the more benign version and can live with it for many years. That’s the conundrum - how do you protect the younger men who present with a high level PSA or other symptoms? alex
Bakerboy, really? The data (see http://www.aihw.gov.au/cancer/data/acim_books/index.cfm) don’t show that. Men aged 45-49 have 0.8 prostate cancer deaths per 100,000 and a prostate cancer incidence of 32.3/100,000. Men aged 75-79 (where there is the highest incidence) have 226 deaths/100,000 in 950.2 cases /100,000. Respectively that’s a death:incidence ratio of 0.25 in the younger men and 0.24 in the older men (although of course no one is saying that prostate cancer tends to kill quickly). Nonetheless, I would not call that difference evidence of “more aggressive form of prostate cancer”. I’d be interested to see some evidence for your claim.
Simon Chapman has highlighted two important issues involving Prostate Cancer management. Both issues are worth ventilating, but the way Simon has conflated them further adds to the confusion which abounds.
The recent pronouncement by the Urological Society on introduction of PSA testing at age 40 is probably scientifically correct if all the Society’s caveats are understood and heeded (if a test at age 40 is below a certain level, no further testing is needed for ten years…..yadda, yadda,,,,). Most GPs did not get this message, let alone potential patients. In my practice I have seen enough worried well forty-somethings with marginally above-average PSA levels who expect to be immediately subjected to biopsy and/or radical Prostatectomy. My point is that the recent pronouncement has just added to the general level of angst in the community, and this leads to inappropriate activity by patients and their doctors.
We do now have increasingly accurate prognostic tools which allow us to determine which Prostate Cancers need to be treated, and which can be safely observed. If we used these tools and convinced our patients to accept conservative recommendations, we would not have the enormous rates of unnecessary incontinence and impotence detailed in the US Preventive Services Taskforce report . Most Urologists understand these issues well and are frustrated by the loss of patients to those who promise surgical cures without consideration of the actual need or proven downside of these treatments.
The next issue is the type of surgery recommended. The Da Vinci robot is latter-day snake oil. It is sold with artful promises, celebrity endorsements and glamorous brochures. It looks like marvelous technology, intuitively one would expect it would do a good job, at least as good as traditional open nerve-sparing surgery. Unfortunately recent results prove the opposite. All major recent studies on the issue have shown that patients treated with the robot have worse rates of incontinence and impotence and no improvement in cancer control.
There is enormous pressure in the Australian Urology community to counter the cartels that have formed in most of our major markets around the robot. In the one market (Melbourne) where the cartel has been broken, there are otherwise ethical practitioners who have felt the need to use the robot to protect their livelihoods. Given that the snake oil salesmen seem to get away with outrageous prices (“gaps” of more than $10,000 are not unusual ) the overall costs to the community in dollars and unnecessary morbidity are significant.
Gavin M and Stephen C both have placed their fingers on a major problem. Well-paid medicos expect - demand - to be taken seriously and demand that consideration of obvious conflicts of interest be brushed aside on the basis of their professionalism or some similar empty boast.
The same kind of problem was apparent in a recent Croaky article where a medico claimed that it is fair for him to start a study of fatigue affecting doctors who, in a hospital environment, work 80 hours per week and/or 36 to 40 hours in a single shift with an a priori assumption that fatigue is countered by the supposed professionalism of the doctors involved.
What bunkum! Try making the same statement in relation to an interstate coach driver, a train driver or an air pilot. All would love to be at their controls and in charge of the lives perhaps hundreds of folk as against a single poor patient who is undergoing a surgical procedure, yet they accept regulation from outside the industry and, indeed, society expects that such regulations exist and that they be complied with. Doctor God, on the other hand, seeks to justify working till he drops, and claims that the instant before contact with the floor, he is still fully functioning and competent.
There appears to be little realisation in the medical fraternity that conflicts of interest and partisan opinions must be accounted for in analyses of cost/risk/benefit of procedures and processes in the medical industry, as in all others.
Doctors are not and never were Gods and are affected by all the human failings and vices. If you disagree, please cite studies to the contrary - I am particularly interested in any study which demonstrates infallibility or other God-like nature of medicos.
Studies and opinions expressed on this and similar matters MUST be made at arm’s length, through dispassionate and uninvolved observers. This essentially disqualifies, in my mind, any claim made by medical or quasi-medical folk on behalf of medical or surgical outcomes, naturopathy, bone-jerking, herbalism and so forth in relation to the claimants’ own craft and experience.
It is simply tosh to believe otherwise.
Where is the controlled study? Where is the peer review? Where are the dollars?
These three questions must be asked and answered before consideration of the opinions presented, whether in Crikey, a consulting room, or in learned journals.
Spectator refers to a key issue: appropriate treatment. Detection doesn’t have to lead to surgical removal of the prostate, if the side effects outweigh the benefit of such treatment.
Surely early detection is better than later detection, when the cancer may have spread outside the capsule, thus increasing the risk of spreading to the lymph nodes. Why not screen, detect, and treat less aggressively?
And today .. the quite conservative American Cancer Society begins to question the wisdom of mass screening for breast and prostate screening http://www.nytimes.com/2009/10/21/health/21cancer.html?_r=1&src=twt&twt=nytimeshealth
Simon Chapman highly slanted article needs a careful reply. I had surgery for prostate cancer in March - this was picked up when I asked for a PSA test following testicular cancer. My PSA was just above normal and prostate was normal size. Fortunately I was referred back to the urologist who performed surgery for testicular cancer who advised a biopsy even though the likelihood of cancer was low. I was a 7 on the Gleeson scale and he and every reputable article and the original oncologist all advised that surgery was the best option even though he was quite clear that there is no way of knowing when it might become a problem. Chapman entirely forgets to mention the age and Gleeson score factors and this is really dangerous if people accept his advice as a medical expert rather than a social policy analyst. Family history is the other major factor to think about.
All the literature on prostate cancer is quite clear that the risks for younger men with potentially aggressive cancer are far higher once it is out of the prostate with successful treatment in terms of radiation, chemotherapy not great in the long term. I opted for robotic surgery my surgeon gave me a completely open and frank assessment of the benefits but with no exaggerated claims and a clear understanding of the risks, he had a preference for robotic as a technique but the choice was entirely mine. He even offered to send me to another specialist for advice on radiation treatment.
He made it clear that if I was in my 60s he would advise a different course. I know other men who are being treated by surgeons with a lower gleeson score and they have been advised to be monitored not to have surgery.
I was out of hospital in 2 days with minimum pain and am nor almost fully continent 6 months later - other side effects will have to wait and see but again I have fully understood the risks and the potential treatments.
I accept and have read all of the debate about screening and find it a very difficult issue in terms of the overall population outcomes and agree that many men with low grade prostate cancer may end up having unnecessary surgery if population screening was introduced.
Having spent 4 months in intensive chemo once I can assure you there are better ways to spend your time - this may have influenced my decision - but not as much as 2 close female colleagues who have lost their husbands\partners to prostate cancer in their mid -late 50s having been detected too late.
My advice - make sure you have a good GP who knows what they are talking about, don’t rely on the digital rectal exam, do have a PSA if there is any family history and yes do think about getting a base line reading in your early 50s. Then make sure you have a good specialist who gives you all of the options.
Don’t make this an ideological conspiracy or a greedy doctor story although that can be an issue - take it seriously and don’t dismiss the risks as Simon Chapman’s article may encourage you to do.
If by chance he does have a high PSA reading one day I will be fascinated to see what follows.
whoa, whoa Peter! My “highly slanted article’? Did or did not the JAMA article report the findings I summarised about the worse outcomes from robotic surgery? Is it true or is it not that the College of GPs not not support PSA screening for any age? Is it or is it not the case that many men who undergo radical prostatecomy would not have died from prostate cancer had they not had the surgery? Has Dr Stricker or anyone else publicised any independently audited outcome results of robotic surgery in Australia? Please don’t shoot the messenger.
Simon
If you are a true messenger then you should also:
Report the rebuttals to the JAMA article including its methodological flaws - the truth in the long run will be that for many surgeons it is a better technical option certainly the hospital stays are less .In my case and relative to every man I spoke to before having the operation who went through the traditional operation the outcome has been better in terms of hospital stay time, pain, bleeding and continence. But it is expensive and there may be over use. The problem is the JAMA article is based on what men report against some fairly loosely defined criteria if the Robot has been over hyped as it well have been that is highly likely to colour the responses. Have you dealt with Tony Costello’s claim that the research conflated two different techniques and the other research he has pointed to if you as just a messenger.
Some urologists attacking the technique are just as self interested as those promoting it as they can’t access it. I agree an independent audit is needed, its benefits shouldn’t be over sold at the end of the day its the surgeons skill that matters - I was given both options and went for the robot on the basis of the explanation of the technique and process.
Report the unambiguous research that says that younger men with aggressive prostate cancer have a much lower level of risk of spread and of dying if they have surgery and the dilemma this creates in terms of working out who should have a PSA test and then a biopsy - yes on a population basis screening is hard to support but the fact is that mens lives are being saved by early diagnosis - or are you saying that the whole Gleeson scale is wrong.
To reiterate my point its a highly complex and changing picture but to turn it into a highly selective attack on the profession rather than outlining the complexities and ambiguities and emphasising the importance of informed choice makes you a protagonist at best I’m afraid to say a dangerous one at worst by not emphasising the need for men to make careful and informed judgements themselves against good advice and evidence.
Peter, have you actually read the JAMA study, or have you just heard da Vinci owners (plainly with massive vested interests) rubbishing it? I just looked at every issue of JAMA since the report was published on Oct 14. There have been no rebuttals published. I would be obliged if you would point me to where these are. The JAMA study looked at a cohort of 8837 men throughout the USA who had undergone radical prostatectomy. It compared the outcomes of those who had retropubic radical prostatectomy (RRP) and those who had had minimally invasive radical prostatectomy (MIRP) with and without robotic assistance. The continence and impotence outcomes were worse in the MIRP group. Public information should be based on studies of large numbers of men randomly selected, not on anecdotes from men who pass good news around to each other nor from those who have vested interests in continuing to promote procedures.
You say “the JAMA article is based on what men report against some fairly loosely defined criteria”. The study was not based on reports from men - -it was based on medical record analysis: postoperative case record reports. I would be pleased to have a look at Tony Costello’s critique and also to see “the unambiguous research ” on younger men. My email is sc@med.usyd.edu.au
Simon