The sheer volume of scientific data and marketing copy aside, the best allies remain information and personal preference.
I read an article today about a new study out of NYU Langone Medical Center and Yale School of Medicine that shows that when hospitals acquire surgical robotic technology, men in that region are more likely to have prostate cancer surgery.
“The use of the surgical robot to treat prostate cancer is an instructive example of an expensive medical technology becoming rapidly adopted without clear proof of its benefit,” said Danil V. Makarov, MD, MHS, lead author and assistant professor, Department of Urology at NYU Langone Medical Center and assistant professor of Health Policy at NYU Wagner School of Public Health. “Policymakers must carefully consider what the added-value is of costly new medical devices, because, once approved, they will most certainly be used.”
I can think of other modalities and techniques about which the same can be said: proton beam therapy vs. intensity modulated radiation therapy, CT vs. MRI vs. other imaging technologies. The fact is, whenever new technologies are introduced, they come with large entry costs, sometimes widely conflicting data and an abundance of marketing messages from eager manufacturers and medical centers who hope to differentiate themselves in highly competitive markets. I remember twenty some odd years ago, smaller medical centers often shared the services of mobile CT and MRI equipment so they could also market the latest technologies and keep patients from defecting to larger, competing institutions. It’s what patients demand. It’s what a free market encourages.
My first thought in reading the article was that it was a matter of reallocation… patients were simply electing to go to elsewhere for the new technology. But then I read: “…hospitals with surgical robots increased surgery cases an average of 29.1 per year while those without robots experienced a decline in radical prostatectomy by – 4.8 cases.” That’s still a net gainof 24.3…
Now, in this day and age where overtreatment of certain prostate cancers is a real concern, I can’t image any well-regarded institution or practice up selling patients to procedures that aren’t necessary. What I find plausible is that with a surgical option that is less invasive and offers some appealing benefits such as not needing to bank blood, shorter hospital stays and smaller incisions, more patients may be willing to entertain the thought of being more aggressive with their treatment selections. This is the area that deserves more consideration:how do you tell a patient who would prefer to have the cancer taken out, perceives an attractive option and no longer wants to consider less invasive and less aggressive options, that they can’t? At this point, they may be less willing to look at the diagnostics numbers more closely and objectively. And, until a physician can definitively tell a patient that his cancer is not a life-threatening variety, what are they to do? There is the ever prevalent threat of malpractice lawsuits.
I have always said that I was dubiously lucky enough to have clear diagnostics data (Gleason scores, percentages of involvement within the prostate, PSA doubling time, etc…) that pointed to aggressive treatment. In my casem surgery. As a result of my research, I was confident that outcomes with open or roboticsurgery are about the same and are more dependent on the surgeon’s experience (number of procedures) with a specific technique. Age can also have more of an effect on outcomes than the difference between open and robotic. Following a long consult with my surgeon and a query into the number of robotic procedures he had performed, along with his outcome percentages for urinary continence and ED, I made my decision to have him perform the procedure robotically. Had he only done open surgery with the same stats, I might have elected for that option based on my confidence levels. Perhaps not. (I’ll admit, I am a bit of a weenie when it comes to incisions.) The most important factor was that I was comfortable with my final decision and went into surgery without reservations.
If a patient is to be comfortable with their treatment choice, aggressive or not, I believe personal preference has to play into the decision process. We are all so very different… I know one patient who chose to have open surgery with only an epidural block. I admire the man, but I certainly couldn’t have done it!
What’s the point of all of this? No matter what the technology, there will always be a plethora of data and confusing–sometimes conflicting–opinions around it until its effectiveness and benefits play out over time, and, until the next great innovation comes along.
Keeping this reality in mind, there is no substitute for us being our own best patient advocates. To this end, our strongest allies remain information harvesting, the advice of a trusted medical professional and a good dose of our personal preferences guiding our final decisions.