Need A Radical Prostatectomy? Find a Hospital Where They Do Many of Them

When it comes to finding a hospital for radical prostatectomy, a Brady study has found a simple rule for potential patients to keep in mind: Experience counts - especially if you want the best chance to be cured.

"Radical prostatectomy is a complex, notoriously difficult surgical procedure," says Bruce J. Trock, Ph.D., associate professor of urology, epidemiology, and oncology, and director of the Brady's Division of Epidemiology. A new study from Brady scientists shows what many in the medical community have known for years: That the best results- fewest side effects, and greatest control of cancer - are found at academic medical centers, where the urologists specialize in this complicated operation.

The study, headed by Robert Wood Johnson Scholar and urology fellow Lars Ellison, M.D., compares the recurrence of prostate cancer at a hospital to the number, or volume, of prostatectomies performed at that hospital. What does hospital volume have to do with the results of surgery? A lot, explains Trock, who also took part in the study - particularly when the procedure is a hard one for surgeons to master. For radical prostatectomy, he says, several studies have examined the link between hospital volume and short-term problems, such as surgical complications, and death up to one year after surgery. But this study, published in the Journal of Urology, is the first to examine whether hospital volume is related to cancer control - the likelihood of that cancer will come back - after prostatectomy.

Ellison and colleagues evaluated 12,635 men aged 65 or older - patients from hospitals in Arizona, California, Connecticut, Iowa, Utah, and Washington State - who underwent radical prostatectomy between1990 and 1994, and who were followed through 1999. The researchers determined hospital volume based on the number of prostatectomies performed in men aged 65 or older during 1990-1994 - low (1-33), medium (34-61), high (62-107) or very high(108 or more). Then they looked for evidence of prostate cancer recurrence in these men- the start of hormonal therapy or radiation therapy more than six months after radical prostatectomy.

They found that the low-volume hospitals had more patients with low-grade disease and local tumor stage, both of which indicate a

"Surgeons at high-volume institutions encounter the fullrange of this diversity,and areprepared to deal with it."

better prognosis. This suggests that hospitals with less experience prefer to operate on the men most likely to do better, explains Trock. Even so, low- and medium-volume institutions had significantly higher rates of treatment for cancer recurrence - 25 percent and 11 percent higher, respectively -than did very high-volume institutions.However, hospital volume did not seem to affect the number of deaths, from prostate cancer or otherwise; Trock believes this is due to the study's relatively short follow-up time of five to nine years, and the low rate in general of death from prostate cancer after radical prostatectomy.

The higher recurrence rates at lower-volume institutions could be because the surgeons' experience - and also their techniques - vary widely. Ellison and colleagues found as much as a 25-percent difference in cancer control between low-and very high-volume hospitals. "The anatomy of the prostate and biology of a tumor can vary tremendously among patients," concludes Trock. "Surgeons a thigh-volume institutions encounter the fullrange of this diversity, and are prepared to deal with it."


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