ASCO Connection is the official membership magazine of the American Society for Clinical Oncology (ASCO). In August 2014, the magazine carried an article by ASCO member Joel B. Nelson, MD (Chair of the Department of Urology at University of Pittsburgh). The title was “The Lack of Value for Robot-Assisted Radical Prostatectomy.”[i] Lack of value? That’s a strong choice of words for a procedure that has gained amazing ground since the FDA cleared it in 2000. Dr. Nelson is not the first person to question what’s behind the surge in robotic radical prostatectomies (RRP). Six years earlier, Dr. Eric Estey (Alberta Urology Institute) published a peer-reviewed journal article called “Robotic prostatectomy: The new standard of care or a marketing success?”[ii] Both his and Dr. Nelson’s title imply that RRP has commercial as well as clinical value, though Dr. Nelson’s article overtly states that the robotics may not meet patient expectations of reduced side effects: “Unbiased population-based studies do not support the widespread claims of improved continence and potency…”
Before going any further, let’s back up a step. As of June, 2014 there were 2153 DaVinci robotic systems in place in U.S. hospitals. With the incredible visual magnification and fully articulated robotic arms, the robot is a great advance in minimally invasive surgery. While prostatectomies are the most common application for the device, it is also used to treat cardiac, gynecologic, kidney and other conditions. The greatest criticism leveled against the robot, as far as I can tell, is that the lack of demonstrated superiority in outcomes raises doubts as to whether the high cost of robotic procedures is justified when there is much need for medical belt-tightening. Dr. Nelson’s article is an example of this argument.
I, too, am concerned about healthcare costs, but I have an additional issue with how inconsistently RRP is backed up by published data in direct-to-consumer internet marketing. According to Mirkin, et al.[iii], “After performing a search and cross sectional analysis of websites that mentioned the procedure, we found that many sites claimed benefits that were unsupported by evidence and that 42 percent of the sites failed to mention risks. Most sites were published by hospitals and physicians, which the public may regard as more objective than pages published by manufacturers.” They go on to state that “unbalanced information” leads to unrealistic expectations on the part of patients.
One of our chief goals in designing our Sperling Prostate Center website was to dedicate an entire section to continuously updated patient information and education based on published research. The section called “Diving Deeper” at https://sperlingprostatecenter.com/patient-resources/ is devoted to bringing peer-reviewed articles to the attention of our site visitors. For every article, we cite the sources of the data we present, data that supports the present and forward-looking world of prostate cancer detection, diagnosis and treatment. For example, currently there is considerable dialogue among experts as to whether Gleason 3+3 cancer is really cancer, and whether it needs to be treated. The jury is out, but until the recent uptick in recommendations that these patients consider Active Surveillance (AS), they have been the targets of urologic surgeons who have strongly urged them to undergo RRP in order to “get rid of the cancer” by nerve-sparing RRP. For countless patients since 2000, this approach may have been overtreatment, leaving them with urinary and/or sexual problems. For men considering AS, our website provides articles on the use of multiparametric MRI as part of a surveillance protocol for Gleason 3+3 cancer because we want men to know that imaging is supported by research as an alternative to surveillance biopsies until need arises. We also offer complimentary second opinions on patients’ image CDs.
Whether or not RRP is worth the cost of the equipment and the procedure is not for us to judge. We respect the right of each prostate cancer patient to choose the treatment he’s most comfortable with, and most assured of to match his disease—including AS. Toward that goal, what is most valuable for patients is to have access to correct, research-based information and education. Without that, patients will continue to be at the mercy of marketing.
[iii] Mirkin J, Lowrance W, Feifer A et al. Directo-to-consumet internet promotion of robotic prostatectomy exhibits varying quality of information. Health Aff (Millwood), 2012 Apr;31(4):760-69.