Bernard L. Schwartz Distinguished Professor of Urologic Oncology
Professor of Urology, Oncology
Johns Hopkins Medicine
Director, Division of Adult Urology
Brady Urological Institute
State-of-the-Art Lecture: Active Surveillance for Prostate Cancer
MRI Fusion Biopsy | Q&A with Dr. H. Ballentine Carter
Dr. Carter is a surgeon, a patient advocate, and a prostate cancer researcher.
Dr. Carter trained in urological surgery at New York Hospital-Cornell Medical Center and at the Brady Urological Institute at Johns Hopkins. He is the only surgeon at Johns Hopkins to have ever collected 4 years of quality of life information on consecutive patients undergoing radical prostatectomy using validated questionnaires (see below graphs). As a surgeon, these data allow him to know how he is doing, and also to allow patients to know what to expect. After performing more than 3500 radical prostatectomies on men from all over the world, he can help men and their partners navigate through a difficult time in their lives, and in most cases return to a life that was present before the diagnosis of prostate cancer.
A patient undergoing the surgery described above could expect to have a carefully performed operation with the best chance of total cancer removal using visual magnification and tactile feedback rarely requiring blood transfusion, and that can be performed in just over an hour. Men are discharged from the hospital on the day after the procedure.
I am often asked why I prefer a standard open operation rather than the robotic approach to radical prostatectomy. The reasons are straightforward:
- Open surgery allows one to see both the forest and the trees. The view of the entire surgical field is restricted with robotic surgery (missing the forest for the trees). Federal regulators are investigating a sharp rise in injury and death reports in robotic surgeries. The reports include severe burns to internal tissue, pierced arteries and organs, and internal bleeding. I believe these are a result of not seeing the "forest" (organs around the prostate) and focusing only on the "tree" (prostate).
- Lack of touch (tactile feedback) with robotic surgery.Surgery to remove an organ (or part of an organ) is essentially the art of safely separating one tissue from another. To do this carefully requires touch to be able to determine when one tissue is adherent to another. Without touch there is an increased risk of leaving prostate tissue behind - an explanation for the finding in some studies that positive margin rates are higher with robotic versus open surgery.
- There is no scientific evidence that men undergoing robotic surgery have better outcomes when compared to open surgery. The popularity of robotic surgery is based on a) monetary rewards from the device maker to physicians to "push" its use, and b) hospital advertising to capture market share and recoup expenses for the device purchase and upkeep. These perverse incentives ignore the lack of scientific evidence that robotic prostatectomy improves outcomes. In fact, a 2013 study from Johns Hopkins published in the British Journal of Urology showed that a delay in discharge due to post-operative complications was almost 4 times more likely for men undergoing robotic compared to open radical prostatectomy. And, a large study from a Medicare population using validated questionnaires showed that when compared to open surgery, men undergoing robotic surgery had no better urinary or sexual function post-operatively. Because robotic surgery has been advertised with unsubstantiated claims, studies show that men undergoing robotic surgery are more likely to suffer regret likely due to unrealistic expectations.
Patient AdvocateOne of the most important aspects of practicing surgery is to understand which patients don't need an operation. As a result, in 1995, Dr. Carter began a large prospective study to evaluate what is now referred to as Active Surveillance for prostate cancer - a program designed to select men who are thought to have small volume cancers that may never need treatment. These men then have the option to be carefully monitored as an alternative to immediate surgery. He believes that men today that are diagnosed with Gleason score 6 cancer are asking the wrong question “What treatment is best”, when they should be asking “Do I need to be treated at all”. In counseling patients regarding the decision to treat or not, Dr. Carter emphasizes the importance of a man’s personal preferences and concerns. For example, many men are willing to accept large declines in quality of life to be rid of a cancer that has minimal chance of causing harm over a decade or more; while others would rather live with a cancer and maintain their quality of life for now. Understanding these patient specific preferences plays a large part in the decision to monitor or treat a cancer when the decision is not a “slam dunk”.
I have found that patients who are faced with decisions about treatment for prostate cancer benefit from talking to others who have already been through this experience. A list of patients that have indicated their desire to help others, and that spans more than a decade of practice, is provided to patients seeking this type of help.
Prostate Cancer ResearcherDr. Carter, Professor of Urology and Oncology, is an internationally recognized expert in the diagnosis and treatment of prostate disease, both cancerous and non- cancerous. He led a panel of experts that wrote the American Urological Association guidelines in 2013 for prostate cancer detection. His book –The Whole Life Prostate Book- is the only comprehensive prostate book for laypeople that offers patients not only up to date information on management options for prostate disease (including cancer), but also approaches to prevention of male health disorders including prostate disease.
He was recently nominated to be a Trustee of the American Board of Urology by the American Association of Genitourinary Surgeons. His term extends from February 2012-February 2018. Dr. Carter's election as a Trustee to the American Board of Urology is a recognition of his exemplary patient care and innovative research in the field of prostate cancer.
The concept of PSA rate of change (PSA velocity) as a marker of prostate cancer presence and aggressiveness, was introduced by Dr. Carter in collaboration with investigators at the Baltimore Longitudinal Study of Aging. He also first described the use of free PSA to predict the behavior of prostate cancer. (For more information read "Deciphering the Results of a Prostate Test "). He was the first to publish data demonstrating that an individual’s personal prostate cancer screening program should be tailored to baseline PSA levels instead of using a “one size fits all” approach. Together with investigators at the Baltimore Longitudinal Study of Aging, Dr. Carter has investigated risk factors for development of prostate cancer and prostate enlargement including diet and life style.