Articles

Prostate Cancer

Effects of Pathologic Stage on the Learning Curve for Radical Prostatectomy: Evidence That Recurrence in Organ-Confined Cancer Is Largely Related to Inadequate Surgical Technique

By: Andrew J. Vickersa lowast , Fernando J. Biancob, Mithat Gonena, Angel M. Cronina, James A. Easthamb, Deborah Schraga, Eric A. Kleinc, Alwyn M. Reutherc, Michael W. Kattand, J. Edson Pontese and Peter T. Scardinob

European Urology, Volume 53 Issue 1, May 2008, Pages 960-966

Published online: 01 May 2008

Keywords: Prostate cancer, Surgical learning curve, Decision analysis

Abstract Full Text Full Text PDF (282 KB)

Abstract

Objectives

We previously demonstrated that there is a learning curve for open radical prostatectomy. We sought to determine whether the effects of the learning curve are modified by pathologic stage.

Methods

The study included 7765 eligible prostate cancer patients treated with open radical prostatectomy by one of 72 surgeons. Surgeon experience was coded as the total number of radical prostatectomies conducted by the surgeon prior to a patient's surgery. Multivariable regression models of survival time were used to evaluate the association between surgeon experience and biochemical recurrence, with adjustment for PSA, stage, and grade. Analyses were conducted separately for patients with organ-confined and locally advanced disease.

Results

Five-year recurrence-free probability for patients with organ-confined disease approached 100% for the most experienced surgeons. Conversely, the learning curve for patients with locally advanced disease reached a plateau at approximately 70%, suggesting that about a third of these patients cannot be cured by surgery alone.

Conclusions

Excellent rates of cancer control for patients with organ-confined disease treated by the most experienced surgeons suggest that the primary reason such patients recur is inadequate surgical technique.

Take Home Message

For patients with organ-confined prostate cancer, recurrence after surgery approaches zero for the most experienced surgeons, suggesting that recurrence in such patients relates to inadequate surgical technique. Analysis of learning curves suggests that about 30% of patients with locally advanced disease cannot be cured by surgery alone.

Keywords: Prostate cancer, Surgical learning curve, Decision analysis.

Footnotes

a Department of Epidemiology and Biostatistics, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

b Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, NY, USA

c Glickman Urological and Kidney Institute, Cleveland Clinic, Cleveland, OH, USA

d Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA

e Department of Surgery, Wayne State University, Detroit, MI, USA

lowast Corresponding author. Memorial Sloan Kettering Cancer Center, 1275 York Avenue, New York, NY 10021, USA. Tel. +1 646 735 8142; Fax: +1 646 735 0011.

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