Variations among experienced surgeons in cancer control after open radical prostatectomy.
OBJECTIVE
Complications and functional outcomes after prostate surgery vary among surgeons to a greater extent than may be accounted for by chance. This excessive variation is known as heterogeneity. We explored whether there is also heterogeneity among high volume surgeons with respect to cancer control after surgery.


METHODS
The study cohort consisted of 7,725 patients with clinically localized prostate cancer treated with open radical prostatectomy at 4 major American academic medical centers from 1987 to 2003 by 1 of 54 surgeons. We defined biochemical recurrence as serum prostate specific antigen 0.4 ng/ml or greater followed by a higher level. Multivariate random effects models were used to evaluate prostate cancer recurrence heterogeneity among surgeons after adjusting for case mix (prostate specific antigen, pathological stage and grade), surgery year and surgeon experience.


RESULTS
We found statistically significant heterogeneity in the prostate cancer recurrence rate independent of surgeon experience (p = 0.002). Seven experienced surgeons had an adjusted 5-year prostate cancer recurrence rate of less than 10% while another 5 had a rate that exceeded 25%. Significant heterogeneity remained on sensitivity analysis adjusting for possible differences in followup, patient selection and stage migration.


CONCLUSIONS
Patient risk of recurrence may differ depending on which of 2 surgeons is seen even if the surgeons have similar experience levels. Surgical randomized trials are imperative to determine and characterize the roots of these variations.
Bianco
Fernando J
FJ
Division of Urology, Department of Surgery, Memorial Sloan-Kettering Cancer Center, New York, New York, USA. fb2271@columbia.edu
Vickers
Andrew J
AJ
Cronin
Angel M
AM
Klein
Eric A
EA
Eastham
James A
JA
Pontes
J Edson
JE
Scardino
Peter T
PT
D000368:Aged; D013502:General Surgery / Q000592:standards / Q000706:statistics & numerical data*; D006801:Humans; D008297:Male; D008875:Middle Aged; D009364:Neoplasm Recurrence, Local / Q000097:blood / Q000453:epidemiology; D017430:Prostate-Specific Antigen / Q000097:blood; D011468:Prostatectomy / Q000706:statistics & numerical data*; D011471:Prostatic Neoplasms / Q000097:blood / Q000601:surgery*
D017430:Prostate-Specific Antigen