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

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.

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.

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.

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.