The Impact of Multidisciplinary Care in a Large Volume Robot-Assisted Radical Prostatectomy Program: A Paradoxical Stage Migration toward More Aggressive Disease

Jospeh F. Renzulli II^*, Michael M. Maddox, Omar Nadeem, Simone Thavaseelan, Gyan Pareek, Anthony E. Mega

Warren Alpert Medical School, Brown University, Providence, USA.

DOI: 10.4236/ojim.2014.44017                

Abstract

Introduction: With the widespread use of robot-assisted radical prostatectomy (RARP), a stage migration to less aggressive prostate cancer (CaP) may be expected in pathological specimens due to over-treatment of low risk disease. It is unclear whether implementation of a multidisciplinary clinic (MDC) model would offset this phenomenon. We sought to analyze our database for possible stage migration in prostatectomy specimens in the setting of MDC. Methods: A total of 262 patients who underwent open prostatectomy (OP) from 2004 to 2006 and 757 patients who underwent RARP from 2007 to 2011 were identified from our prospective database. The implementation of MDC occurred concurrently at the time of RARP initiation. Demographic data, pathology, positive margin rates along with standard CaP reporting data were recorded. The two groups were compared with regards to percentage of cases stratified by Gleason grade. Results: The number of CaP cases managed at our institution increased considerably after the introduction of robotics and MDC. There was a significant decrease in the patients with Gleason 6 CaP undergoing RARP as compared with OP (p = 0.001). Additionally, RARP was performed on a significantly greater percentage of Gleason 7 disease (p < 0.001). When comparing pathological stage, there was a significant increase in the incidence of pT3 disease following RARP (p < 0.0001). Conclusions: The introduction of a MDC and minimally invasive radical prostatectomy did not result in an increased application of surgery for the treatment of low risk prostate cancer. This highlights the importance of MDC in a large volume RARP program.

Keywords

Prostate Cancer, Robotics, Multidisciplinary Care

Conflicts of Interest

The authors declare no conflicts of interest.

References

[1]	Siegel, R., Desantis, C., Virgo, K., et al. (2012) Cancer Treatment and Survivorship Statistics, 2012. CA: A Cancer Journal for Clinicians, 62, 220-241. http://dx.doi.org/10.3322/caac.21149
[2]	Menon, M., Parulkar, B. and Baker, S. (1995) Should We Treat Localized Prostate Cancer? An Opinion. Urology, 46, 607-616. http://dx.doi.org/10.1016/S0090-4295(99)80289-1
[3]	Schroder, F., Hugosson, J., Roobol, M., et al. (2012) Prostate-Cancer Mortality at 11 Years of Follow-Up. The New England Journal of Medicine, 366, 981-990. http://dx.doi.org/10.1056/NEJMoa1113135
[4]	Andriole, G., Crawford, E., Grubb, R., et al. (2012) Prostate Cancer Screening in the Randomized Prostate, Lung, Colorectal, and Ovarian Cancer Screening Trial: Mortality Results after 13 Years of Follow-Up. Journal of the National Cancer Institute, 104, 1-8. http://dx.doi.org/10.1093/jnci/djr500
[5]	Wilt, T., Brawer, M., Jones, K., et al. (2012) Radical Prostatectomy versus Observation for Localized Prostate Cancer. The New England Journal of Medicine, 367, 203-213. http://dx.doi.org/10.1056/NEJMoa1113162
[6]	Barbash, G. and Glied, S. (2010) New Technology and Health Care Costs—The Case of Robot-Assisted Surgery. The New England Journal of Medicine, 363, 701-704. http://dx.doi.org/10.1056/NEJMp1006602
[7]	Lowrance, W., Eastham, J., Savage, C., et al. (2012) Contemporary Open and Robotic Prostatectomy Practice Patterns among Urologists in the United States. Journal of Urology, 187, 2087-2093. http://dx.doi.org/10.1016/j.juro.2012.01.061
[8]	Litton, G., Kane, D., Clay, G., et al. (2010) Multidisciplinary Cancer Care with a Patient and Physician Satisfaction Focus. Journal of Oncology Practice, 6, e35-e37
[9]	Aizer, A.A., Paly, J.J. and Efstathiou, J.A. (2013) Multidisciplinary Care and Management Selection in Prostate Cancer. Seminars in Radiation Oncology, 23, 157-164. http://dx.doi.org/10.1016/j.semradonc.2013.01.001
[10]	Gomella, L.G., Lin, J. and Hoffman-Censits, J. (2010) Enhancing Prostate Cancer Care through the Multidisciplinary Clinic Approach: A 15-Year Experience. Journal of Oncology Practice, 6, e5-e10
[11]	Aizer, A.A., Paly, J.J., Zietman, A.L., Nguyen, P.L., Beard, C.J., Rao, S.K., et al. (2012) Multidisciplinary Care and Pursuit of Active Surveillance in Low-Risk Prostate Cancer. Journal of Clinical Oncology, 30, 3071-3076. http://dx.doi.org/10.1200/JCO.2012.42.8466
[12]	Madeb, R., Golijanin, D., Knopf, J., Kowalczyk, J., Feng, C.Y., Rashid, H., et al. (2011) The Impact of Robotics on Treatment of Localized Prostate Cancer and Resident Education in Rochester, New York. Journal of Endourology, 25, 573-577. http://dx.doi.org/10.1089/end.2010.0498
[13]	Draisma, G. and De Koning, H. (2003) MISCAN: Estimating Lead-Time and Over-Detection by Simulation. BJU International, 92, 106-111. http://dx.doi.org/10.1111/j.1464-410X.2003.4409x.x
[14]	Cooperberg, M., Lubeck, D., Mehta, S. and Carroll, P.R. (2003) Time Trends in Clinical Risk Stratification for Prostate Cancer: Implications for Outcomes (Data from CaPSURE). Journal of Urology, 170, S21-S27. http://dx.doi.org/10.1097/01.ju.0000095025.03331.c6
[15]	Hankey, B., Feuer, E., Clegg, L., Hayes, R.B., Legler, J.M., Prorok, P.C., et al. (1999) Cancer Surveillance Series: Interpreting Trends in Prostate Cancer—Part I: Evidence of the Effects of Screening in Recent Prostate Cancer Incidence, Mortality, and Survival Rates. Journal of the National Cancer Institute, 91, 1017-1024. http://dx.doi.org/10.1093/jnci/91.12.1017
[16]	Cooperberg, M., Broering, J., Kantoff, P. and Carroll, P.R. (2007) Contemporary Trends in Low Risk Prostate Cancer: Risk Assessment and Treatment. Journal of Urology, 178, S14-S19. http://dx.doi.org/10.1016/j.juro.2007.03.135
[17]	Harlan, S., Cooperberg, M., Elkin, E., Lubeck, D.P., Meng, M.V., Mehta, S.S. and Carroll, P.R. (2003) Time Trends and Characteristics of Men Choosing Watchful Waiting for Initial Treatment of Localized Prostate Cancer: Results from CaPSURE. Journal of Urology, 170, 1804-1807. http://dx.doi.org/10.1097/01.ju.0000091641.34674.11
[18]	Stephenson, R. and Stanford, J. (1997) Population-Based Prostate Cancer Trends in the United States: Patterns of Change in the Era of Prostate-Specific Antigen. World Journal of Urology, 15, 331-335. http://dx.doi.org/10.1007/BF01300179
[19]	Cooperberg, M., Broering, J. and Carroll, P. (2010) Time Trends and Local Variation in Primary Treatment of Localized Prostate Cancer. Journal of Clinical Oncology, 28, 1117-1123. http://dx.doi.org/10.1200/JCO.2009.26.0133
[20]	Jhaveri, F., Klein, E., Kupelian, P., et al. (1999) Declining Rates of Extracapsular Extension after Radical Prostatectomy: Evidence for Continued Stage Migration. Journal of Clinical Oncology, 17, 3167-3172.
[21]	Moul, J., Wu, H.Y., Sun, L., McLeod, D.G., Amling, C., Lance, R., et al. (2002) Epidemiology of Radical Prostatectomy for Localized Prostate Cancer in the Era of Prostate-Specific Antigen: An Overview of the Department of Defense Center for Prostate Disease Research National Database. Surgery, 132, 213-219. http://dx.doi.org/10.1067/msy.2002.125315
[22]	Albertsen, P., Hanley, J., Barrows, G., Penson, D.F., Kowalczyk, P.D.H., Melinda Sanders, M. and Fine, J. (2005) Prostate Cancer and the Will Rogers Phenomenon. Journal of the National Cancer Institute, 97, 1248-1253. http://dx.doi.org/10.1093/jnci/dji248
[23]	Thompson, I., Canby-Hagino, E. and Lucia, M. (2005) Stage Migration and Grade Inflation in Prostate Cancer: Will Rogers Meets Garrison Keillor. Journal of the National Cancer Institute, 97, 1236-1237. http://dx.doi.org/10.1093/jnci/dji286
[24]	Smith, E., Frierson, H., Mills, S., Boyd, J.C. and Theodorescu, D. (2002) Gleason Scores of Prostate Biopsy and Radical Prostatectomy Specimens over the Past 10 Years. Is There Evidence for Systematic Upgrading? Cancer, 94, 2282-2287. http://dx.doi.org/10.1002/cncr.10457
[25]	Epstein, J. (2000) Gleason Score 2-4 Adenocarcinoma of the Prostate on Needle Biopsy: A Diagnosis that Should Not Be Made. American Journal of Surgical Pathology, 24, 477-478. http://dx.doi.org/10.1097/00000478-200004000-00001
[26]	Korman, H., Lanni Jr., T., Shah, C., Parslow, J., Tull, J., Ghilezan, M., et al. (2013) Impact of a Prostate Multidisciplinary Clinic Program on Patient Treatment Decisions and on Adherence to NCCN Guidelines: The William Beaumont Hospital Experience. American Journal of Clinical Oncology, 36, 121-125. http://dx.doi.org/10.1097/COC.0b013e318243708f