Journal of the National Cancer Institute Advance Access published online on July 24, 2007
JNCI Journal of the National Cancer Institute, doi:10.1093/jnci/djm060
| ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
ARTICLES |
The Surgical Learning Curve for Prostate Cancer Control After Radical Prostatectomy
Affiliations of authors: Departments of Epidemiology and Biostatistics (AJV, AMS, DS) and Surgery (FJB, JAE, PTS), Memorial Sloan-Kettering Cancer Center, New York, NY; Department of Quantitative Health Sciences (MWK) and Urological Institute (EAK), Cleveland Clinic, Cleveland, OH; Departments of Epidemiology and Biostatistics (AMR) and Urology (JEP), Wayne State University, Detroit, MI
Correspondence to: Andrew J. Vickers, Memorial Sloan Kettering Cancer Center, 1275 York Ave, New York, NY 10021 (e-mail: vickersa{at}mskcc.org).
Background: The learning curve for surgery—i.e., improvement in surgical outcomes with increasing surgeon experience—remains primarily a theoretical concept; actual curves based on surgical outcome data are rarely presented. We analyzed the surgical learning curve for prostate cancer recurrence after radical prostatectomy.
Methods: The study cohort included 7765 prostate cancer patients who were treated with radical prostatectomy by one of 72 surgeons at four major US academic medical centers between 1987 and 2003. For each patient, surgeon experience was coded as the total number of radical prostatectomies performed by the surgeon before the patient’s operation. Multivariable survival–time regression models were used to evaluate the association between surgeon experience and prostate cancer recurrence, defined as a serum prostate-specific antigen (PSA) of more than 0.4 ng/mL followed by a subsequent higher PSA level (i.e., biochemical recurrence), with adjustment for established clinical and tumor characteristics. All P values are two-sided.
Results: The learning curve for prostate cancer recurrence after radical prostatectomy was steep and did not start to plateau until a surgeon had completed approximately 250 prior operations. The predicted probabilities of recurrence at 5 years were 17.9% (95% confidence interval [CI] = 12.1% to 25.6%) for patients treated by surgeons with 10 prior operations and 10.7% (95% CI = 7.1% to 15.9%) for patients treated by surgeons with 250 prior operations (difference = 7.2%, 95% CI = 4.6% to 10.1%; P<.001). This finding was robust to sensitivity analysis; in particular, the results were unaffected if we restricted the sample to patients treated after 1995, when stage migration related to the advent of PSA screening appeared largely complete.
Conclusions: As a surgeon's experience increases, cancer control after radical prostatectomy improves, presumably because of improved surgical technique. Further research is needed to examine the specific techniques used by experienced surgeons that are associated with improved outcomes.
| CONTEXT AND CAVEATS Prior knowledge Surgical outcome is widely believed to depend on the experience of the surgeon, but actual surgical learning curves based on surgical outcome data are rarely presented. Study design An analysis of the association between a surgeon's prior experience with performing radical prostatectomy and biochemical recurrence of prostate cancer (as defined by the serum prostate-specific antigen level) after radical prostatectomy in patients with clinically localized prostate cancer. Contribution Surgical experience was associated with the probability of patients being biochemical recurrence free after radical prostatectomy. Implications The surgical technique of experienced surgeons may differ from that of less experienced surgeons, and opportunities for continued surgical education are needed. Limitations Differences in case mix among surgeons may have contributed to residual confounding. Patient follow-up differed among institutions and surgeons. Accordingly, surgeon experience could not definitively be linked causally to patient outcome in this observational study. Biochemical recurrence is of uncertain clinical relevance to patients.
|
Manuscript received February 13, 2007; revised May 18, 2007; accepted June 13, 2007.
CiteULike 
Connotea 
Del.icio.us What's this?
Find additional patient-related information at:
Related Articles in JNCI
-
IN THIS ISSUE
J Natl Cancer Inst 2007 99: 1137.[Extract] [Full Text] [PDF]
- Press Release: Success Rates for Prostate Cancer Depend on Experience of Surgeon
- Liz Savage and Andrea Widener
J Natl Cancer Inst 2007 99: 1137.[Extract] [Full Text] [PDF]
- Key to Finding Quality Cancer Hospitals and Surgeons Is Finding Out How Much They Practice
- Mary Beckman
J Natl Cancer Inst 2008 100: 86-91.[Extract] [Full Text] [PDF]
This article has been cited by other articles:
|
|
 |
|
  J. C. Hu, X. Gu, S. R. Lipsitz, M. J. Barry, A. V. D'Amico, A. C. Weinberg, and N. L. Keating Comparative Effectiveness of Minimally Invasive vs Open Radical Prostatectomy JAMA, October 14, 2009; 302(14): 1557 - 1564. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 A. J. Stephenson, M. W. Kattan, J. A. Eastham, F. J. Bianco Jr, O. Yossepowitch, A. J. Vickers, E. A. Klein, D. P. Wood, and P. T. Scardino Prostate Cancer-Specific Mortality After Radical Prostatectomy for Patients Treated in the Prostate-Specific Antigen Era J. Clin. Oncol., September 10, 2009; 27(26): 4300 - 4305. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 E. R. Haut, D. C. Chang, A. J. Hayanga, D. T. Efron, A. H. Haider, and E. E. Cornwell III Surgeon- and System-Based Influences on Trauma Mortality Arch Surg, August 1, 2009; 144(8): 759 - 764. [Abstract] [Full Text] [PDF]
|
|
|
|
|
|
A. K. Tewari, J. K. Jhaveri, K. Surasi, N. Patel, and G. Y. Tan Benefit of Robotic Assistance in Comparing Outcomes of Minimally Invasive Versus Open Radical Prostatectomy J. Clin. Oncol., October 20, 2008; 26(30): 4999 - 5000. [Full Text] [PDF]
|
|
|
|
|
|
J. C. Hu In Reply J. Clin. Oncol., October 20, 2008; 26(30): 5001 - 5002. [Full Text] [PDF]
|
|
|
|
|
|
M. L. Blute Radical Prostatectomy by Open or Laparoscopic/Robotic Techniques: An Issue of Surgical Device or Surgical Expertise? J. Clin. Oncol., May 10, 2008; 26(14): 2248 - 2249. [Full Text] [PDF]
|
|
|
|
|
|
J. C. Hu, Q. Wang, C. L. Pashos, S. R. Lipsitz, and N. L. Keating Utilization and Outcomes of Minimally Invasive Radical Prostatectomy J. Clin. Oncol., May 10, 2008; 26(14): 2278 - 2284. [Abstract] [Full Text] [PDF]
|
|
|
|
 |
|
 P. C. Walsh, T. L. DeWeese, and M. A. Eisenberger Localized Prostate Cancer N. Engl. J. Med., December 27, 2007; 357(26): 2696 - 2705. [Full Text] [PDF]
|
|
|
|
 |
|
 With Radical Prostatectomy, the Experience of the Surgeon Matters Journal Watch Oncology and Hematology, August 14, 2007; 2007(814): 7 - 7. [Full Text]
|
|