Sunday, August 25, 2013

A Personal Perspective on Testing for Prostate Cancer - 2013

As an urologist who has subspecialized in just the area of prostate disease, I see men with prostate cancer every working day.  Every single consulting session I will see a number of men with advanced prostate cancer who are enduring either the side effects of the palliative drug treatment for advanced prostate cancer or who are battling the complications associated with advanced prostate cancer. 

In Australia, over 3,200 men die from prostate cancer each year.  This is a greater number than the women who succumb to breast cancer each year.  Irrespective of what the denominator is in terms of how many are diagnosed each year, as the second greatest cause of cancer specific deaths in men (after lung cancer), it is continues to astound me that anybody can sweep these facts under the carpet.  But to give the denominator, number of men who are diagnosed with prostate cancer in Australia each year currently sits at just under 20,000. 

It is well recognized that not all men diagnosed with prostate cancer will actually die from their cancer but will instead die from some other cause.  The majority of cancers will follow an indolent slow growing course and will never cause harm. This said, these statistics include men who in spite of dying with prostate cancer (and not from it) have significantly suffered from the effects or treatment for advanced prostate cancer or were successfully treated for prostate cancer that otherwise have lead to a prostate cancer related death.

The overzealous desire to fight prostate cancer has had significant consequences.  Many men who did not need treatment have been unnecessarily treated and of these, some have experienced complications associated with radical treatment.  This has been a huge problem and with its recognition, attempts are being made to rectify this problem.  Significant progress has been made in getting smarter about who needs treatment and also reducing the risks of complications associated with treatment.

Not all men diagnosed with prostate cancer need treatment.  There has been a major shift towards treating early stage prostate cancer conservatively by what we call active surveillance and watchful waiting.  Active surveillance differs from watchful waiting in that curative treatment has not been ruled out.  Active surveillance is a program of monitoring that attempts to strike the right balance between avoiding the overtreatment of prostate cancer yet at the same time attempting to minimize of missing any window of opportunity to deal with the cancer should it subsequently prove itself to be more aggressive than originally anticipated. Protocols for active surveillance vary but contemporary monitoring includes monitoring PSA blood test levels and periodically carrying out MRI scans of the prostate or progress biopsies.  If there is evidence that suggests that the cancer is more aggressive than originally thought or if the disease appears to have progressed, the option of treatment remains on the cards.  Watchful waiting implies that curative treatment has been ruled out and monitoring is carried out until such time that the disease progresses to justify the commencement of palliative drug treatment in the form of androgen deprivation therapy (commonly referred to as hormone therapy).

There has also been a significant improvement in side effects associated with treatment for prostate cancer.  The majority of men with very early stage prostate cancer are candidates for treatment that can spare both urinary and sexual function.  Commonly, detractors against prostate cancer testing attempt to connect urinary incontinence and erectile dysfunction as being consequential certainties associated with prostate cancer testing.

Now on the issue of PSA blood testing, there have been quite polarized views on whether it should be performed or not.   I have tried to avoid the word ‘screening’ because I think that most of us who have in the past supported this approach have moved very much towards selected testing on an individual basis where each man as an individual has the opportunity to participate in the decision to undergo testing or not.

I think that it is time that those who so vehemently oppose PSA testing should acknowledge that an entity that is the second greatest cause of cancer related death in men is a public health problem.  It is also time to stop assertions that if a PSA test is abnormal that it leads to a high risk of complications with the biopsy and that should cancer be confirmed that it some form of aggressive intervention will invariably follow.  Additionally, we have moved on from the outcomes of 20years ago in that treatment is NOT invariably associated with incontinence and erectile dysfunction.

The answer for PSA testing lies somewhere between widespread population screening and totally opposing any form of testing at all.  I am looking forward to those who have vehemently opposed any form of testing for prostate cancer to acknowledge this as well.

Concluding Comments

I am NOT in favor of indiscriminate population screening for prostate cancer.  Men should be risk assessed as to whether the benefits of making a diagnosis of prostate cancer individually outweighs the attendant risks.  Men should NOT be denied the right to participate in any discussion regarding a decision to undergo prostate cancer testing or not.  I completely disagree with any assertion that there should no discussion about prostate cancer testing unless raised by the patient.  When men are counseled on making a decision as to whether or not they wish to be tested, they should be given information that is relevant to their individual circumstances.  The Melbourne Consensus Statement on Prostate Cancer Testing is a good place to start. 

Acknowledgement:  I wish to thank Katy Hanlon for creating the images that accompany this piece.  Katy can be contacted on Twitter @khanlon 

Thursday, August 15, 2013

Update on Transitioning From Open to Robotic Assisted Radical Prostatectomy

Since I first blogged on robotic surgery in July last year, it has become the predominant manner by which I perform prostate cancer surgery.  I continue to offer open surgery and particularly for those who cannot afford the cost of robotic surgery - it is important to not make them feel inadequate and that there is a reasonable alternative approach available.  Robotic surgery for prostate cancer is rapidly moving towards being the predominant manner by which prostate cancer surgery is being performed in Australia.  

Sydney had the lowest concentration of robotic platforms per capita in any of the mainland capital cities and for many years there was only one hospital with the technology.  Subsequent to a second hospital acquiring the technology and the significant marketing that followed, the dominos fell rapidly.  In the space of less than two years, there are now 7 hospitals in Sydney which now gives it the highest concentration of robotic platforms in Australia.  The competition for men to undergo robotic assisted radical prostatectomy has never been more palpable.  Many surgeons feel they are being forced into the technology on the basis of marketing pressures rather than being able to transition into the technology on their own terms. There has been a sense of urgency for surgeons to enter into the robotics space and enthusiastically offer their services and there is this sense of urgency for surgeons to announce that they have reached a certain threshold of cases or are now the most experienced with the technology for a particular geographical part of Sydney.  The tenor of competitive marketing material has lowered to include accusations of how one hospital is much more expensive than another without any factual basis to make such statements.  

One surgeon's overzealous attempts to market his services went to the extremes of misleading readers of his training credentials and true level of experience.  His marketing was excessive to the extreme that he has been formally counselled by his university and reprimanded by our professional body, the Urological Society of Australia and New Zealand.  He has also been referred to the Royal Australasian College of Surgeons for investigation of breach of its Code of Practice and to the Australian Health Practitioners Regulatory Authority for investigation of breach of advertising regulations.  Others have provided more carefully crafted glossy brochures to referring general practitioners and it is becoming increasingly common to have the addition of the term "Robotic Surgeon" to their professional stationary.  I hope that I will continue to not have to resort to these measures in order to maintain my existing sub-specialised practice in prostate surgery.  

I digress for just a moment to recount how a mentor of mine once told me when I started practice that the best advertising you could do was to look after your patients well.  In other words, your patients would be your best advertisement. Maybe this is an old fashioned approach but for as long as this still works for me, then I will consider myself fortunate.  That said, back on topic.

I feel very grateful for the fact that I have been in the position to pick and choose which patients that I felt that I could safely offer robotic surgery instead of open surgery in my hands.  This enabled me to get comfortable with doing easier cases before taking on more complex cases.  I am now comfortable with offering robotic assisted radical prostatectomy for all men for whom surgery is an appropriate option.   I have been extremely fortunate to have undergone transitioning to this technology in an era where training tools (such as the virtual reality simulator), an established technique and surgical proctoring were so readily available to me.  I am particularly grateful for my friends and colleagues Damien Bolton (Melbourne) and Peter Swindle  (Brisbane) making an effort to come to Sydney to help train me without accepting any remuneration for my over and above minimum expected proctored cases.

Robotic surgery is clearly here to stay and to be fair, the advantages of  less pain and quicker recovery have turned out to be more profound than what I had anticipated.  It was very easy to be critical of such claims when I had no personal experience with the technology and given that I had thought that my patients undergoing open surgery were doing just fine with no need improve upon this.  It has also been gratifying to see that my cancer clearance rates and recovery of continence are unchanged although I have an impression that the latter is actually better.  It is too early to know for sure of my outcomes for recovery of erectile function but my impression at this early stage is that it may in fact be better.  In spite of great anxiety and trepidation in making this transition, it is pleasing to report that my personal experience with adopting robotic surgery has turned out to be a particularly positive and exciting period of my surgical career.   My only disappointment has been the aggressive marketing and collegial fragmentation seen in association with the rapid uptake of the technology.  As one very astute GP wrote to me regarding a second opinion referral that he had sent to me: "I am concerned that the joy of a new technology and one's desire to expand their series is impacting on clinical decision making" - I sincerely hope that the race to adopt robotic surgery does not become a prostate harvesting exercise after the huge leaps forward that have been made in embracing conservative approaches such as active surveillance for those with clinically insignificant disease.