Prostate surgery and risk
One way to identify the best doctors in the country is to watch where public figures go for treatment. After announcing last week that he had prostate cancer, Massachusetts senator and Democratic presidential hopeful John Kerry had the gland removed by Dr. Patrick Walsh of Johns Hopkins University Hospital in Baltimore.
Regarded by many as the best prostate surgeon in the world, Walsh told reporters before the surgery that his new patient had an excellent prognosis: a 97% chance of being cancer-free for the next 10 years, a 99% chance of avoiding incontinence and a 90% chance of retaining full sexual function. The surgery itself went “by the book,” Walsh said afterward, adding that Kerry was “out of the woods.”
That kind of success was unheard of even 15 years ago, and it’s largely due to Walsh’s pioneering of a removal technique that spares nerves near the prune-sized gland, which is just behind the genitals.
But not everyone has access to world-renowned surgeons such as Walsh. Some 220,000 men each year learn they have prostate cancer, and thousands of them make treatment decisions without ever hearing about nerve-sparing surgery. In prostate removal, one slip of the knife can mean a life of impotence. Some surgeons have a proven track record of sparing the nerves; others do not. Many do not provide patients with documented complication rates.
“The result is that patients have only a vague idea of what the risks are,” said Dr. Peter Carroll, chief of urology at UC San Francisco. “This is simply not good enough.”
In prostate cancer, eliminating the cancer is only the first battle. Most qualified urologists report five-year cure rates of 80% or higher, using radiation treatments, surgical removal or a combination. (Some patients also do well with no treatment at all; prostate cancer is often slow growing and may never spread beyond the gland.)
But the possible complications from treatment are frightening, and highly variable: 1% to 7% of men end up incontinent after surgery; and 20% to 80% are left impotent. In part, these differences are due to the type of patient being treated. As a rule, for instance, men in their 50s do much better than those in their late 60s or 70s; and those with high blood pressure do worse than those with normal blood pressure. Many of the men whom Walsh treats are, like Kerry, 59, in otherwise good health.
Yet the surgeon’s skill and experience are a big factor. To spare a man’s potency, the doctor must separate from the prostate two webbed bundles of nerves that are critical for erection -- without leaving any prostate tissue behind. Specialists say that doing it well, and reliably, takes training and lots of practice. Many surgeons don’t do it often enough to predict their outcomes.
“You need to be doing a lot of them, and doing it steadily, always refining your technique,” said Carroll. Several large-scale studies of Medicare patients have driven home this point: More experienced doctors get better results, whether they’re operating on the heart, knee or prostate.
No one knows for sure how to quantify this craft. But the best surgeons tend to do at least one surgery a week, and have been specializing in nerve-sparing procedures for two years or more, urologists say. “A surgeon who’s doing at least 50 of them a year can give you an idea of what his rates of complications are,” said Dr. Ian Thompson, chief of urology at the University of Texas Health Science Center in San Antonio. “Doing a lot of the surgeries also allows you to continually improve your technique.”
Most major cities have at least a dozen specialists in this top category. Often they have trained at the country’s premier prostate institutions, such as Johns Hopkins, UC San Francisco, Memorial Sloan-Kettering Cancer Center in New York, UCLA and Washington University in St. Louis. Generally speaking, for good surgeons, post-surgery rates of incontinence are no higher than 5%, and rates of impotence no higher than 50%. Many men who retain full sexual function require Viagra to do so. “Again, it all depends on the health of the patient going in,” Thompson said, “but as a rule erections usually aren’t what they were before the surgery. For some men they are; but for most they’re going to be softer and not last as long.”
Complication rates of individual surgeons aren’t published; there’s no way for a prospective patient to get them except from the doctor. “Ask about everything,” said Carroll. “You need to sit down with the surgeon and ask directly: How many surgeries do you do a year? What are your complication rates? What are your numbers for men like me? The surgeon has an obligation to provide the answers.”
There is no way to know how accurate the numbers are, but when a doctor with a good reputation can provide specific complication rates, it’s a very good sign. Some will put the numbers in writing, or pass on the names of previous patients. If the numbers aren’t satisfactory, patient advocates urge men to keep looking.
One prostate cancer patient who insisted on numbers from his doctor is Don Pugh, a 57-year-old software consultant in Woodside, who was diagnosed with the disease in 2000. After weeks of haggling with his HMO, Kaiser Permanente, Pugh demanded -- and got -- a paid referral out of the plan to a surgeon at Stanford who had trained with Walsh.
Now fully recovered, Pugh has spent two years advising men who are in the same fix. “My sense is that 90% to 95% of men with the cancer have no idea what the risks of surgery are and ask no questions -- they just lie down on the table,” he said. “Especially when it comes to this disease, and this surgery, you have to take charge of your own health care.”
John Kerry sure did.
