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Monday, April 9, 2007

Choosing a Surgeon - Part I. Considerations

[updated March 31, 2016]

This is a two part series on choosing a surgeon. The first part discusses why it is important to choose a good surgeon and the second part discusses finding one.

Choosing A Surgeon - Part 1. Considerations
Choosing A Surgeon - Part 2. Finding a Surgeon

Choosing a surgeon wisely can be important:
  1. Urologists tend to recommend surgery and radiation oncologists tend to recommend radiation. [Note: actually, in my case, my rad onc did recommend surgery.]
    [PMID: 10866869]. Also see this news release on a Memorial Sloan Kettering study reported at the 2007 ASCO Prostate Symposium which reached similar conclusions.

  2. Where you live can make a difference to which treatment is recommended. In particular, Florida urologists have higher trust in radiation [PMID: 12385923] and American urologists are more aggressive than Canadian urologists. Different primary care physicians have different approaches toward PSA testing [PMID: 19296843 ]. [PMID: 10751858]. The National Prostate Cancer Coaliation rates the efforts of each US states in fighting prostate cancer in their [2008 report card] on prostate cancer.

  3. Even when credible evidence exists (biopsy technique, preoperative staging) significant proportions of urologists in both US and Canada continued to practice contrary to existing data.
    [PMID: 10751858]

  4. Training for laparascopic surgeons is unsystematic. "The lack of a standardised, evaluated training procedure needs to be overcome. Structured training programmes and transference of gained experience into daily practice are essential to provide urology with expert laparoscopists." EAU-EBU Update, April, 2007
    In fact, many Canadian laparascopic surgeons begin practicing with no formal mentoring!
    [PMID: 16813706]

  5. Your chance of complications after surgery are lower for high volume surgeons in high volume hospitals. See [PMID: 11948274] and this [presentation] or [Flash version]. In December 2008 Andonian et al., at the 26th World Congress of Endourology (WCE) in Shanghai presented evidence of measurable changes in brain function among more experienced surgeons. See [link]. In some hospitals group decision making in a team fashion is done where all the surgeons and relevant displines get together to decide on protocols that all will use. The information packages available to patients can vary significantly from hospital to hospital but will generally be common to all surgeons at a particular hospital and even elements of the surgical protocols, such as how many lymph nodes to sample, may be. (Incidentally it has also been found that it is also true that radiation at high volume centers have better outcomes. See [PMID: 26972640])

  6. Not only are complications reduced but the likelihood of positive surgical margins, i.e. where cancer extends across the region cut by the surgeon showing that it was not all removed, is lessened for surgeons with greater volume.
    [PMID: 14634399]

  7. 5-year biochemical recurrence (i.e. rise in PSA suggesting cancer has returned) is more likely the less surgical experience the surgeon has. The chart to the right from the 2006 ASCO talk of Bianco et al rises rapidly and then around 250 changes the rate of ascent so that it rises at a lesser rate although it continues to rise so there is no plateau. Thus a surgeon who has done 250 surgeries will have better outcomes than a lesser experienced one on average and as experience increases from that point onward the outcomes continue to improve but at a much slower rate. This AUA 2007 presentation also concluded that surgeon experience was an independent predictor of recurrence after local treatment in organ confined disease. This figure from the July 2007 JNCI [Fulltext] covering 7765 cancer patients and 72 surgeons shows freedom from biochemical recurrence curves for surgeons of varying experience. Note how the curve associated with surgeons having done more than 999 surgeries lies above all the others showing that their patients had the fewest recurrences of cancer. There were some limitations to the study: "Differences in case mix among surgeons may have contributed to residual confounding. Patient follow-up differed among institutions and surgeons. Accordingly, surgeon experience could not definitively be linked causally to patient outcome in this observational study. Biochemical recurrence is of uncertain clinical relevance to patients." [link]. In a 2010 J Urol paper Vickers et al indicate that for laprascopic surgery the absolute increase in risk for positive margins is 4.8% for a surgeon with the experience of 10 surgeries vs. a surgeon with 250 surgeries. See [PMID: 20952022]. Also see the table on page 8 of [Niall Corcoran presentation].

  8. For two surgeons with the same volume of surgeries there can still be signficant differences due to technique. "Fellowship training followed by an academic practice was significantly associated with superior learning and outcomes." [link]The chart to the right from the 2006 ASCO talk of Bianco et al shows the probability of freedom from recurrence at 5-years for each surgeon. A dot represents the probability and the horizontal line is a confidence interval. Note that large differences are possible. Also note that most urologists who do US radical prostatectomy have nowhere near the 250 surgery level of experience. Savage and Vickers determined the typical annual radical prostatectomy caseloads of surgeons in the United States by analyzing "data from 2 independent data sets for 2005, that of a nationally representative sample (Nationwide Inpatient Sample) and a complete record of all hospital discharges from New York State (Statewide Planning and Research Cooperative System). They found that "more than 25% of United States surgeons conducting radical prostatectomy in 2005 performed only a single procedure. Approximately 80% of surgeons performed fewer than 10 procedures per year and, thus, are unlikely to reach the plateau of the learning curve during their surgical career." [PMID: 19836787]

  9. Whether the surgeon has maintained or lost interest in radical prostatectomies and the degree to which trainees participate in the surgery may make a difference too. In one data series there was a slight worsening of outcomes after 50 surgeries which may be due to one of these causes. [link]

  10. surgeons connected with different hospitals may have quite different waiting times for surgery.

  11. US doctors have conflicting incentives which may cause some to choose treatments and procedures based on what makes most business sense to them rather than what makes most medical sense for the patient. See these June, 2007 NY Times articles: [NY Times link 1] and [NY Times link 2].
  12. There is large variations in the quality of care in the US. Discussing cancer, in general, (not specifically prostate cancer) in a July 27, 2007 New York Times article Dr. Stephen B. Edge, the chariman of surgery at the Roswell Park Cancer Institute in Buffalo says: "It’s quite surprising, but the quality of cancer care in America varies dramatically ... It’s scary how much variation there is." A 2007 study done of urologists in France show that which doctor you get can determine whether or not you get treated for ED with only half of all doctors systematically prescribing ED treatments to all patients. These tended to be the younger ones and the ones that performed more RPs. See [PMID: 18042217]
  13. Actual performing surgeon. Make sure you understand who will actually be performing the surgery. You may have assumed that the experienced surgeon you spoke to prior to surgery will actually do the surgery whereas, in fact, a trainee under him will actually do it. This is more likely at teaching hospitals. Another problem to watch out for is a surgeon that has several operating rooms going at once so that he is moving among them and is not giving his full attention to any one. This is mentioned by a practicing surgeon on this TV Interview. The fact that overwork leads to errors seems intuitively reasonable and has been documented in other medical situations. For example, in [PMID: 15767214] the authors write: "At the beginning of each month, there is a spike in government payments to individuals, resulting in a beginning-of-the-month spike in purchases of prescription drugs and in increased pharmacy workloads. Studies suggest that pharmacy error rates increase with increased workloads. These facts raise an important and previously unanswered question: is there a spike in fatal medication errors at the beginning of each month? We examined all United States death certificates from 1979-2000 (> 47,000,000 deaths) and showed that medication error deaths for which the decedent was dead on arrival or died in the emergency room or as an outpatient spiked by 25% above normal at the beginning of each month. This beginning-of-the-month spike (25% +/- 4%) was larger than for any other major cause of death. The beginning-of-the-month spike did not vary by socioeconomic status and was not larger for substance abusers than for others. Five explanations for the findings were tested. Evidence suggested that the spike in medication error deaths cannot be solely attributed to a spike in the consumption of alcohol or drugs. An increase in pharmacy error rates might play a role."
  14. Teaching Hospitals and High Caseload Hospitals. Patients at teaching hospitals had few complications after surgery, fewer transfusions an shorter hospital stays. Hospitals with heavy caseloads also had better results.[PMID: 21944081].

Several of these points are also mentioned in this May 2007 SUO talk by Scardino.

Freehand laprascopic surgery requires the most experience followed by robotic surgery followed by open surgery. Thus with freehand laparascopic or robotic its even more important to ensure experience although its very important with open surgery too, as discussed previously above.

Assessing technique can be difficult; however, one can
  • review the Principles of Surgical Therapy section on pages MS-12 and MS-13 (pages 39 and 40 of the PDF document) of the 2007 NCCN Physician Guidelines which will give the reader insight into surgical procedures for prostatectomy.

  • If a surgeon has trained in multiple approaches such as (a) open and robotic, or (b) open and laparascopic, the additional training may be indicative of potentially superior technique. Also certain elements of robotic and laparascopic training apply to open and knowledge of open is useful for robotic and laparascopic surgeries.

  • Where the surgeon trained, whether he had fellowship training (where he was mentored by an experienced surgeon) and who his mentor was are items of interest.

  • Just meeting the doctor will give you a sense of his age and that will likely be related to his experience.

  • Ideally the doctor maintains statistics of his outcomes but if not one surrogate might be to use the outcomes from the institution where he trained after factoring in experience. For example, many laparascopic surgeons are trained in Cleveland and outcomes for the Cleveland Clinic are published here. Statistics should be taken with a grain of salt since they can easily be manipulated. Appropriate stratification of outcomes into patient risk groups, e.g. using d'Amico risk categories (discussed in the Favorable Outlook section of Advice for the Newly Diagnosed) or Gleason score is the minimum necessary or else the figures can be made to look better by only treating or including low risk patients. Even if this is done there are various factors which are unlikely to be explicitly recorded, such as comorbidities (e.g. by excluding diabetic patients), which can skew the results to make them look more favorable.

  • One noteworthy approach used in some European centers is the Barre method [PMID: 17196737]

  • Some of the questions in the Questions to Ask Doctor post (also linked under Key Posts to right) may be helpful here.

  • This summary of the Whitmore Lecture at the 2008 AUA meeting by Dr. Patrick Walsh (pioneer of nerve sparing prostatectomy, e.g. see Nerve Sparing Turns 25) briefly discusses the evolution of surgical techniques involved in prostatectomy.

  • It should not be surprising that experienced surgeons do better since inexperience has been linked to medical errors in other circumstances as well. For example, in [PMID: 20512532] there is a documentation of the "July Effect": "Each July thousands begin medical residencies and acquire increased responsibility for patient care. Many have suggested that these new medical residents may produce errors". The authors write: "Inside medical institutions, in counties containing teaching hospitals, fatal medication errors spiked by 10% in July and in no other month [JR = 1.10 (1.06-1.14)]. In contrast, there was no July spike in counties without teaching hospitals. The greater the concentration of teaching hospitals in a region, the greater the July spike (r = .80; P = .005). These findings held only for medication errors, not for other causes of death."

Other Parts of this Series

Choosing a Surgeon - Part 1. Considerations [current]
Choosing a Surgeon - Part 2. Finding a Surgeon [next]

Other Surgery Posts

RP vs. LRP vs. RLRP - Part 1. Open Surgery (RP)
RP vs. LRP vs. RLRP - Part 2. Laparascopic Surgery (LRP)
RP vs. LRP vs. RLRP - Part 3. Robotic Surgery (RLRP)
RP vs. LRP vs. RLRP - Part 4. What Surgeons and Others Say

Lymph Node Dissection

Inguinal Hernia and Prostatectomy

Seminal Vesicle Ablation

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