How many surgeries are enough?

I just did a little Googling regarding the learning curve for DaVinci prostatectomies.  So far, everything I've found seems to point to no significant improvement in outcomes after a rather low number of robotic procedures  Most of the studies I've read reach a conclusion similar to the following:  "Conclusion: RALP is a feasible and reproducible technique, with a short learning curve and low perioperative complication rate. Even during the initial phase of the learning curve, good results were obtained with regard to postoperative complications and oncological outcome."  The link to the abstract of this study is here:  http://adsabs.harvard.edu/abs/2007SPIE.6424E..26L

I've only been visiting HW for five months, but I must say I've seen as many negative outcomes from big-name, well known cancer centers as I've seen from anywhere. 

I'm not trying to be contrary here, and of course I believe we all want a competent surgeon, but just where does this idea that the surgeon must have performed 700, or 1000, or 3000 surgeries in order for us to have confidence in his abilities originate?  Can someone please point me to objective proof of this assertion?

Post Edited (clocknut) : 1/16/2011 2:06:24 PM (GMT-7)

There are definitely studies showing the learning curve over hundreds of operations here.   They've been discussed here multiple times before.  The trouble with this HW forum is that its memory only lasts a few days, and it is impossible to search and find these old posts.  The same issues and questions pop up over and over again; sometimes the best answer gets posted, sometims not.  Someone needs to set up a system of keywords and search functions so old answers can be effectively recycled.

In the meantime, someone needs to pop up and reanswer this question.

My doctor's totally subjective view is that the learning curve pretty much flattens out after about 250 surgeries. Your mileage may vary.

My surgeon had lots of experience with both open, laparoscopic (before robots) and then with da Vinci.

However, another da Vinci surgeon, also with lots of experience, said that patients needed to go beyond numbers and really check out a surgeon with people like anesthetists, OR nurses, pathologists, and the nurses who work the urological surgical wards. Find out who doctors are going to when they need surgery.

As for numbers, she said surgery was not unlike baking a chocolate cake. Some people could bake a great cake quickly, others baked awful cakes 500 cakes later. As I had a relative who thought she could make great cakes, which cakes might be useful for putting under spinning wheels when stuck, but not much more, and who must have made thousands of these rock hard cakes, I knew what she was talking about.

My wife's father was an anesthetist, my wife an OR nurse. From dinner table conversation I'm quite convinced that not all surgeons are created equal --- that substantial differences exist in skill and outcomes. And sometimes it is the ones with lots of experience who would be last on the list my father-in-law, or wife, would choose.

I think numbers of surgeries are interesting, and certainly a factor, but I worry that reliance on numbers could lead to a too superficial due dilgence if people put too much emphasis on simple numbers and not results.

Sheldon AKA Sleepless

I brought this question up when I saw new member "Robs" being advised that the surgeon he had chosen, a surgeon who has done 450 prostatecomies, 150 of which were DaVinci and the other 300 open, was probably not sufficiently experienced, and that he should find someone who has done at least 700, or better yet 1,000 DaVinci procedures.

I felt badly for "Robs."  If I had gotten that sort of answer five months ago, when I was getting ready for surgery, I'd have been thoroughly demoralized.  "Robs" was given a lot of good advice, but it was clear to me that in terms of selecting a surgeon, he had done his due diligence, he had selected a surgeon with great care and after thorough consideration, and that he was looking for approval and reinforcement regarding his decision.  He said that his doctor has a wonderful reputation among his peers.

I realize that we all want to stress to newcomers the importance of choosing the best surgeon available to them.  But if we start giving these folks the impression that they're taking a great risk if their surgeon hasn't done at least 700 or 1000 procedures, I think we've raised the bar way too high.

clocknut, I don't mind a high bar when it comes to picking a surgeon. My concern is that the number of surgeries bar be recognized for what it is, an interesting number, but not one you'd want to make the primary, or even significant one, to pick a surgeon on.

Sheldon AKA Sleepless

An, as usual, says it well.  I don't recall anyone ever saying that number of surgeries is the ONLY criteria for selection of a surgeon.  But I think it's pretty clear that experience is usually a very important criteria.  There are other things that need to be considered as many have pointed out.  And, there are obviously going to be times that the doctor who performs his first robotic surgery is going to perform it well.

But...if we are all about giving sound advice to our newly diagnosed friends, I personally think it is incumbant upon us to tell them that one of the ways to get better odds of success in their procedure is to select an experienced surgeon.  That does not mean 50; it means 250+ IMHO.

Tudpock (Jim)

 

The cancer treatment centers identified as a Comprehensive Cancer Center (CCC) are found on a "sticky" at this site...go HERE and scroll about 90% of the way down the page. What added value is there is choosing a Comprehensive Cancer Center (CCC), or an expert dedicated to prostate cancer (in our case, for example) treatments in private practice?     While the US indeed has some of the best cancer care in the world, there are clear disparities in cancer diagnosis and treatments documented in a report last year between the top cancer centers and the community settings (local hospitals and generalists in private practice).   [Note that this report was not prostate cancer-specific; it addressed all cancers, but some prostate cancer examples were given.]   First, in order to tee-up the heart of the comparison, consider the two opposite ends of the spectrum:   On the one end of the spectrum , some tumors are so non-threatening and their treatment so standard, that it shouldn’t (and doesn’t) matter where you go…your chances are pretty good either way.   For common cancers such as prostate, breast, and colon, the surgery can be very well done in non-CCC settings and the survival rates are comparable to those at the elite cancer centers.   Five years after the nine most common cancer surgeries, the study reported 62% of the patients treated at the CCC centers were alive, compared to 58% at the community hospitals…a difference, but not a huge difference.     On the other end , against some cancers, even the top medical wizards are helpless.   Ted Kennedy’s case of glioblastoma was referenced; he lived 15 months after his diagnosis despite treatment at the Duke University CCC, just slightly over the median survival period.     What about the millions of cancers cases  in the middle —those that are neither hopeless nor straightforward (or as straightforward as cancer can be)?   Here is where differences in outcomes based on where you are treated were most noteworthy.   Fox Chase Cancer Center (in Philadelphia, a CCC facility) provided this data, for example, on the five-year survival of stage-4 prostate cancer patients which highlights the differences:   71% at Fox Chase versus 38% nationwide average.   The quality-of-care differences found in the study were, interestingly, not related to who has the newest, coolest multi-million dollar machine, in which case one could forgive small community hospitals for lagging behind.   Instead, it comes down to such basics as experience ; to getting the correct diagnosis ; to whether doctors address holistic aspects of diet, exercise, and psychological health; to whether doctors routinely test tumors for molecular markers that can guide therapy; to whether multi-disciplinary care is coordinated or haphazard; to how well doctors monitor patients (after surgery, radiation, or chemical treatment) in order to minimize the chance that the cancer will recur.   Examples were provided in the report, three of which I will bullet here:   ·          Prostate cancer patients already know the importance of expert biopsy pathology readings.   The physician-in-chief at MD Anderson (CCC site) estimated that patients traveling to Anderson have an incorrect diagnosis from a community pathologist about 5 to 10 percent of the time.   Clinically important diagnostic errors can lead to improper or incomplete treatment.  From my personal experience, although I had an initial biopsy reading from Bostwick (known expertise in prostate pathology), when I moved from my local urology generalist who diagnosed me to a CCC my slides were re-read for confirmation at the CCC pathology lab. ·          Another rule that we prostate patients also already know about surgery is to select experienced surgeons .   Outcomes for complex surgeries have significantly disparities between top cancer centers and community hospital settings.   For tough surgeries, you want the doctor who’s been around the block, so to speak; surgeons at the top centers have generally sharpened their teeth elsewhere first.   Furthermore, length of stay and rate of surgical complications are lower at the top centers versus community settings. ·          It was interesting (to me, this was one of the most interesting aspects) how the report characterized a general difference between the approaches of oncologists in the two settings.   Doctors in the community setting (generally) report that there is a lot of art in the treatment of cancer, whereas oncologists at top centers say it’s a science .   “Art” might sound desirable and even personal—my oncologist isn’t blindly following a recipe in treating me!—but it covers a lot of sins, notably the tendency of some doctors to pick treatments that worked for other patients, even though those results might have been statistical flukes.   The “recipes” are well established (see the link to the NCCN Clinican's Guidelines for Prostate Cancer in the original posting) by the National Comprehensive Cancer Network (NCCN).     The third bullet (above) notwithstanding, the top cancer centers were also found to have a much stronger ethic of trying anything and everything when cases turn desperate.   The report highlights that this aspect does not show up in five-year survival data, but can make a huge difference to a patient who gets to celebrate one more wedding anniversary or the birth of a grandchild.     After this report was published last year, the National Cancer Institute (NCI) launched a quality improvement program to help raise the bar at the community cancer center programs.   Here’s a link outlining the program:   http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2764567/   The Association of Community Cancer Centers (ACCC) has also responded (following “encouragement” by the federal government, insurance providers, and medical specialty societies) with a training & education program directed at improving adherence to Clinical Practice Guidelines.   See here:   http://accc-cancer.org/education/education-guidelines.asp     Now, fellow HW participants, when your friend tells you they have been newly diagnosed with cancer, you can now point out that while the local community hospital might go a great job of making them feel welcomed and well “cared for”, and they will probably have good results , you now understand why they should consider one of the NCI-designated Comprehensive Cancer Centers for the best possible results .   Can good care be found outside of the CCCs [i.e., in community hospital settings or at private generalists]?  Absolutely.  Will there be people who feel that they had unfavorable experiences at these centers [the CCCs]?  Absolutely.  But taking the broad view, these centers [the CCCs and the private expert specialists] would absolutely be considered the cream of the crop . As JohnT indicated (slight re-phrasing by me)...in medical care, one should strongly consider going for the best possible care.

clocknut said...

Nor does it surprise me that there would be disparities between our nation's top cancer centers and local hospitals staffed with "generalists in private practice."  I would certainly expect trained oncologists and board certified uro/surgeons to achieve better results than a "generalist" in private practice."  I understand that to mean they're comparing specialists to GP's or family practitioners (am I wrong?) 

No, you misunderstood.  The comparison was like-for-like.

The facilities identified as CCCs are the top quality facilities specifically focused on cancer treatment, not other ailements.  "CCC" is a designation by the National Cancer Institute.  USNews also ranks Univ of Chicago (#15) and Northwestern (#27) as the top cancer treatment centers in the region based on their list.  LINK    If I wanted orthopedic work done in Chicago, I would (and I did) go to Rush; cancer, to one of the CCCs.

I agree, by the way, with the key point of not trying to place seeds of doubt 8-days before a patient's scheduled operation.

I absolutely agree with An on this.  If our only role is to say, "Great decision, good luck" then why bother?  Anyone can hear that from his doctor.  Our real value added, besides being supportive, is to help educate men and their families so they can make informed decisions.  Providing comments 8 days before the procedure is a heck of a lot better than 8 days after, IMHO.

Tudpock (Jim)

If you ever were to bet on a golf match, would you bet on Tiger Woods or the local golf pro ?

It only stands to reason that the more surgeries a dr does, the more proficient he becomes.

However, there is the raw ability vs experience. Many golfers will play all of their lives and never be nearly as good as Tiger was his first year in the pros.

Goodlife asks: "If you ever were to bet on a golf match, would you bet on Tiger Woods or the local golf pro ?"

I'd be going with Tiger. But, if we were at a PGA this week and I was betting on who would finish first, Tiger or one of the other golfer's, I'd not be paying much attention to how many games they'd played in their career. No doubt the number of games, and even the number of times they've played a particular course, is a factor, but there are other more important critical factors to consider. So too with surgeons.

Unfortunately for the most part all we have as patients to go on with surgeons is generally somewhat broad brush stroke information such as number of surgeries. I doubt very much when a PCa surgeon needs an RP that they're basing their decision on whose table to lie down on, on simply number done. It won't be a first time surgeon, but after the number is somewhere north of 50 I suspect other factors (average length of surgery, post surgical complication rates, blood loss, cool head in a crisis among them) take over. This is information a doctor can find out about, some documented, some word of mouth from respected sources. It is information that is difficult and sometimes impossible for non-medical patients to access, and so we are left with seeing in a glass darkly and making do with what we have.

There is no easy solution for a non-medical person to get the information we'd all like to have. But I always encourage new PCa people (and isn't it amazing how many phone calls you get from guys who have just got the news) to think about the sort of criteria their doctor would use in deciding on a treatment, or a treatment person, and then using whatever networking they can to find the answers.

It is amazing how connected we all are once you begin to dig into networking. While it may be six degrees between anyone and someone else, often it is just one or two.

An, others in this thread, thank you for your thoughts. All interesting and helpful. A great thread. In the end all any of us want for ourselves, our loved ones, our friends, is the best shot. Figuring out how to get it is important stuff.

Sheldon AKA Sleepless

I had to go to two different hospitals for tests, where my surgeon practices as well. I asked at the volunteer desks about him, and they found some of the long-time volunteers for me to talk to. In both cases the reports were very good (one male volunteer had been an open RP patient of my surgeon some years ago).

Also got some feedback from men who had been treated at other facilities.

Just another source of grass-roots information.