Postive Surgical Margin rates of Open versus Robotic, 3%, 8%, etc.

I'm going to have a prostatectomy in the weeks ahead and have seen two good surgeons. One has only done open surgeries over his 20+ years and has done about 1,400 of them. The other has done about 500 open and then switched to daVinci eight years ago and has now done 700 of those.

When asked the question on what their positive margin rate was for organ-confined patients in my category (Gleason 6, 3+3, T1C, 1 core of 12 with cancer), the open surgeon said 3% and the daVinci surgeon said 8%. The open surgeon is passionate about his statistics and has meticulously collected them for 20 years. He says he and only 1 or 2 others in the country have such statistics on their surgeries. I'm not sure the daVinci surgeon is that careful with his numbers although he is one of the best in my big city and very well-regarded.

I'd prefer to go the daVinci route due to the assumption that it will be less invasive for me though I'm not sure I believe these claims 100%. There are several well done studies (Univ. of Michigan, Vanderbilt) that show daVinci prostatectomies are not any easier to recover from than open procedures, don't reduce blood loss, and are not less painful.

I'm going to get both these surgeons to clarify how they came up with their numbers and over what time period and exact patient demographics. But, if they turn out to really be 3% for the open surgeon and 8% for the daVinci surgeon, doesn't it make sense to go with the open surgeon who has a 5% less-chance of leaving cancer behind? Is an 8% positive margin rate for daVinci high? I know Walsh says across all surgeons at Hopkins and over 10K surgeries, the organ confined cases showed a 1.3% positive margin (pg. 295). He doesn't seem to clarify whether that includes open and robotic as I believe they use daVinci at Hopkins as well.

Edward,

From every clinical indicator you've provided, you have only a tiny, microscopic amount of prostate cancer. There are many men your age who likely have more PC than you have who will never know they have it, and will likely die of something other than PC. Many men with your clinical diagnosis forego radical treatments in favor of changing their lifestyle (diet/nutrition, exercise and stress reduction) to keep their PC fully under control. With the small amount that you have, it is unlikely that you will have a positive margin no matter which surgery technique you choose.

I hope this helps...

Ed,

You have to be careful in how you interpret the data. For truely organ confined that has been confirmed after surgery, the rate of positive margin for low risk PC is about 5%. (pathological staging). For low risk characteristics with clinical staging (pas and gleason) the number is 15%.

This is because the clincal staging (the information you have in which to base a decision) may not be accurrate. The cure rate across major institutions for clinically defined low risk PC is 85% for surgery and 95% for pathological confirmed low risk.

The rate of positive margins is very surgeon dependent. Scardino at MSK published data that showed that the best surgeon had a positive margin rate of 11% and the worst a 45% with an average of 24%. This is across all gleason grades and the rate for low risk is much lower.

Therefore you real risk of a positive margin going into surgery is 15% and if confirmed after surgery that it was indeed a localized G6 is about 5%.

All that being said, I agree with Casey that you have a very good chance of having clinically insignificant PC which is common in most men, and any radical treatment will more likely do more damage than the cancer ever would.

JohnT

With all due respect, questionaboutit, in case you hadn't heard, we are in the midst of a prostate cancer overtreatment epidemic—men with the smallest amounts of prostate cancer being aggressively treated when very likely they did not need aggressive treatment at all. With the clinical characteristics provided by Edward, there is nothing less than what he has that is still called "prostate cancer."

If his doctor, who is probably also one of his possible surgeons, is not telling him this, then it is clearly in his best interest to obtain this information from somewhere...and experienced guys on this forum are probably as good an initial source as any.

It is intuitively obvious to the casual observer that nobody is a doctor here...

I had the DaVinci and the worst part of recovery was the catheter.  Otherwise, it didn't seem like I'd even had surgery.

I would think the DaVinci is less invasive than the open.

I wouldn't spend too much time investigating the surgeons statistics.  There are too many variables involved, including the fact that guys that aren't doing as well are less likely to respond to post surgery surveys.

 

normek, PSA in Aug was 4.3 ng/mL.

Age doesn't effect amount of cancer he has...the smallest amount possible based on what he reported here: "Gleason 6, 3+3, T1C, 1 core of 12 with cancer".

While I did not advise Edward that he "doesn't need surgery, radiation or seeds", I did relate that many "men with your clinical diagnosis forego radical treatments." Then, you may have not noticed, I replied more directly to his question about positive surgical margins.

Do you "get it" now, normed?

Edward, unforutnately, I don't think there is any input beyond what I've already said on the likelihood of you having a PSM for either approach, either doctor.

Have you run your clinical inputs in the MSK nomogram yourself? Try it here:
http://www.mskcc.org/applications/nomograms/prostate/

I entered your info in the MSK nomogram, and it says you have a 98% of progression-free probability after 10-years. It appears to me that 10-years is as far out as it goes.  I cannot tell how someone is able to use the MSK nomograms to project out further than 10-years.

edited after Edwards' correction

Post Edited (Casey59) : 1/14/2011 3:25:11 PM (GMT-7)

Edward,
Pete Scardino and Bill Catalona, both very highly regarded in their combined 70 years+ in treating prostate cancer, were present at an American Urological Association meeting I attended last year in San Francisco. At that conference both were very adamant that in their experience surgery still presents the best chance at a cure for low and medium risk prostate cancers. Pete Scardino get's quoted as saying certain thing that often get misinterpreted in online forums and I think it's important to note. He does clearly outline in his book that a bad surgeon is not uncommon and that factor does reduce your percentages of a successful operation when not carefully selecting an experienced surgeon.

The prostate cancer nomograms at the Memorial Sloan Kettering website are derived from the urological and radiological centers at MSK and can provide you predictive outcomes depending on what treatment you might select. Your doctors claims are reasonably in line with these nomograms.

It is my understanding that while there are chances of positive margins at any risk level, positive margins do not necessarily determine if a treatment was successful, but rather only show if you are at increased risk for biochemical failure. Successful treatment of prostate cancer can be measured numerous ways but the most logical is biochemical failure and prostate cancer specific mortality. Positive margins at surgery is one of the most commonly misinterpreted ways to determine success. Because surgery is recommended before any radio therapies, it is with full understanding that if positive margins are present, radiation is still within standard treatment protocol of the patient but that even that may be unnecessary. It's important to note that a very large number of men who had positive margins never have a relapse of the disease after treatment.

I hope this information may help you...Good luck in your journey...


PS: I am 4 yours after my RP in February. I had positive margins and local mets in my seminal vesicles. I did some followup therapies and to date I have never had a rise in PSA (still undetectable).

Tony

Hello Edward,

You ask some good and legitimate questions. I had open surgery, at the time (2008) in my area, robotic surgery was too new and only a total of 15 for prostate cancer had been done. My surgeon had almost 30 years experience, doing all open surgery. Prostate surgery is major and complex surgery either way. We have men here that had open surgery and only stayed 2 days in the hospital, and men that had robotic that stayed a week. Averages are just that, averages. I needed 4 1/2 days in the hopsital for mine, but had good insurance, so that part didn't matter to me.

As far as bleeding, that is getting to be more of an urban legend from the past. Severe bleeding and blood replacement is very rare in modern open surgery. Also, the argument of magnification is often blown way up, there are some advantages to that issue with robotic, but a good open surgeon with lit and magnified head sets can see just fine.

A lot of RP surgery involves complex sutures and stiching, the tactile feel of a good, experienced open surgeon is hard to replace with a robot. I liked knowing that my surgeon had his hands in fingers in there, and with his experience level, he knew what things should feel like.

Also, you don't have the being filled with gas issues with open surgery, some men here have reported terrible problems with gas and pain issues.

As far as postive margins, one surgical method over the other isn't going to determine that. The cancer is invisible to the surgeon, either method, there is no dotted line to follow. A good surgeon does the best he can. A positive margin can happen in a G6 case as easily as a high grade case. Lot of factors there at work.

In some surveys, perhaps not fully scientific, it almost looks on the surface, that men are suffering higher rates of ED and incontinence via robotic surgery. I think the jury is out on that one, but worth looking into and thinking about.

You want the best surgeon you can get with whatever rescources you have at your disposal, that is my advice. Whether you heal up from several smaller holes, or one larger incision, the complexity of the surgery is the same inside.

Take your time and choose well, there is no re-play button on your choice of a primary treatment if needed. On the surface, looks like your numbers might make you a good candidate for "seeding", so by all means, seek and get the advice of a good radiation and medical oncologist.

David in SC

Thanks so much everyone for all the helpful comments so far. I forgot to mention that I did see two well-regarded radiation oncologists about brachytherapy. I'm lucky to have so many experts in that field in my city as it mostly started here. The radiation experts told me that surgery was a better option for me due to being 52 years of age because there is a slight risk of radiation side effects in later years. I was hoping to have seeds as it sounded relatively simple. That was the only time I wished I was older than I am!

So Ed, you got a lot more information than you bargained for.. Don't fall into the trap of focusing on a single issue..Margin percentages are very hard to accurately calculate and in the end, are not that important as part of the over-all picture..There are many men here with reoccurrences that had negative margins..

one sees this ans similar statements quite often:

"This means that the vast majority of those with prostate cancer will not die from it. It is frightening to think of the unnecessary surgery that is being carried out. "...

The FACT is 32,000 men died of prostate cancer last year...Much depends on your age..If you are 70 or 80, as many men diagnosed with PC are, then active surveillance is a no brainer...Chances are you WILL die from something other than PC...But if you are 45-50-60 years old with a life expectancy of 20-30-40 years, that's a long time to expect your PC will remain "indolent" and harmless.

There is a lot of LUCK involved with the successful treatment of PC..ALL of the treatments have SERIOUS side effects and potential complications..There is no agreement in the medical field as to the best treatment method and the internet is rife with conflicting claims based mostly on anecdotal evidence, hearsay and personal opinion..

Have you read any books on the subject? Walsh's book is good, very detailed, but from a surgeons viewpoint..The latest book out, "Winning the battle Against Prostate Cancer " by Dr. Gerald Chodak contains the results of the latest studies and he goes to great lengths to remain unbiased..Just the facts...

Surgery does offer some advantages.. the entire prostate can be examined and your true "stage" can be determined. With G-6, a successful surgery means you are done..If it fails, radiation can be used as a back-up treatment and a cure is still possible..If money is an issue, Surgery is much cheaper than radiation..

The downside? five years post surgery, 80% of patients who choose it have serious ED issues..30-40% have incontinence issues, 60-80% report their penis was shortened...

You and I are at opposite ends of the PC spectrum..I was Gleason 9..Chose surgery, robotic, Post surgery PSA 0.9 (PSA 7 at biopsy) 100% continent, 100% impotent..Suffered a hospital acquired staph infection in lower abdomen, six days in hospital, a month on IV antibiotics...two weeks with an abdominal drain..It's not always "a piece of cake".....I'm now undergoing salvage radiation and hormone therapy in a last ditch effort..

Best of luck to you as you begin your journey..

questionaboutit said...
BillyMac,

I had my first biopsy in June, 2010. It found no clearcut sign of cancer, only some cells that were suspicious for cancer on the left side. The second biopsy in August found definite cancer on the left side and some suspicious cells on the right side. The cancer was staged as a Gleason 6. Surgery was Sept 9. I had cancer throughout the gland with tumors on both sides and one focally positive margin and a large amount of Gleason 4's. I ended up a 2Tc, Gleason 6 with the 4's noted beside the score. The pathology report did not include cancer volume but the surgeon, looking at the slides, said about 85%. I can't remember if they did 35 or 45 samples but all were cancer.

My doctor said he was glad that I did not put off the surgery until winter or take six months to raise money to go to Mexico for ultrasonic ablation. I think men with PCa should be very wary of the concept of indolent, non-aggressive or insignificant PCa. There are no safe cancers.

I think you misinterpret the statistics that derived from the autopsies of 50 year old men. Had these men not died from heart attacks, wrecks or other causes at the young age of 50, the undetected and untreated PCa may well have killed them a few years later. It does not make PCa any less dangerous just because some men die earlier from other causes. It still needs to be detected and dealt with.

No, you are misinterpreting the data. If 30% of 50 year old dead men have identifiable Pca revealed at autopsy then by extrapolation 30% of not dead 50 year old men will have identifiable Pca. Using your criteria that once Pca is identified, then out she comes baby, means that 30% of 50 year old men need to have their prostates removed. That is clearly outrageous as only 3% of the male population die from Pca. Nobody here diagnosed Edward ------ his doc did. His doc said Gleason 6, 1 out of 12 positive, Stage T1C PSA 4.3 (the 12 month increase from 3.2 is a cause for concern). Based on that diagnosis by his doctor, the suggestion by Casey and JohnT to proceed with caution is sound. Active surveillance does not mean forget about it. If on active surveillance, given those stats, it would be prudent to have another biopsy in 6 months and 24 cores would be better than 12. The opposite advice "Holy s*it you've got cancer, chop it out!" is every bit as bad as "just forget about it"
Bill

Post Edited (BillyMac) : 1/15/2011 2:33:18 AM (GMT-7)

John, I’m trying to grasp all this PC info, stats and percentages. In one post you agree with Casey that Edward has a very good chance of insignificant PC, where radical treatment would likely do more damage than the cancer ever wood. In another post you quote Hopkins data on what constitute insignificant PC.
With the info that Edwards posted, how are you able to determine his psa density is <1.5 and that his positive core was not over 50%, to come up with the conclusion that “there is a very good chance is PC is insignificant.
Also Hopkins do not recommend management of PC for Men in their 50’s and with a family history of PC.
I just think advise is given or suggestions are being made on this forum without knowing all the relevant or required information.