The rapid uptake of robotic prostatectomy and its collateral effects†
See referenced original article on pages 54-62, this issue.
The shift in radical prostatectomy practice patterns toward robotic procedures has had substantial collateral effects, impacting the delivery, access, and cost of prostate cancer care in the United States. In this issue of Cancer, Stitzenberg and colleagues examine how the uptake of robotic surgery has influenced centralization of prostate cancer surgery and effected travel distances for patients seeking prostate cancer surgery. Undoubtedly, robotic surgery has changed the face of prostate cancer care in this country, but still more research is needed to further understand how delivery, access, and cost of health care are impacted by technological innovation.
The emergence and subsequent rapid uptake of robotic radical prostatectomy has changed the face of prostate cancer care in the United States (US). Aggressive direct-to-consumer marketing by hospitals and the surgical robot manufacturer have helped create a demand for robotic prostate surgery, despite studies showing little benefit in functional or oncologic outcomes of robotic over open radical prostatectomy.1-3 Currently, the majority of all radical prostatectomies performed in the US are done robotically, with 2009 estimates ranging from 69% to 85%.4, 5 This shift in prostatectomy practice patterns has had substantial collateral effects, likely impacting the delivery, access, and cost of prostate cancer care.
Using 2000 through 2009 inpatient discharge data from three northeastern states, Stitzenberg et al6 examined how the uptake of robotic surgery has influenced centralization of prostate cancer surgery and affected travel distances for patients seeking prostate cancer surgery. Their hypotheses were borne out by their data analysis. The most dramatic increases in radical prostatectomy volume were centralized at high-volume centers offering robotic surgery, and the proportion of patients traveling at least 15 miles for radical prostatectomy nearly doubled during the study period. Furthermore, these authors found that the total number of radical prostatectomies performed annually for hospitals studied in the tri-state region of New York, New Jersey, and Pennsylvania increased from 8115 in 2000 to 10,241 in 2009 (26%); during the same time frame, the number of hospitals performing radical prostatectomy decreased from 390 in 2000 to 244 in 2009 (37%). The substantial increases in surgical volume were seen almost exclusively at very high-volume centers (classified as such based on their year 2000 prostatectomy volume numbers [>105/y]) with robotic capacity. The odds of having surgery at a very high-volume hospital increased approximately 6-fold (odds ratio, 6.04; 95% confidence interval, 5.74-6.37) during the study. As the authors point out, the centralization of radical prostatectomy is likely multifactorial. However, their work and the work of others show that robotic surgery uptake potentiates the centralization of prostate cancer care and has likely influenced its delivery, access, and cost.
DELIVERY OF RADICAL PROSTATECTOMY
The widespread use of prostate-specific antigen (PSA) screening in the US during the 1990s initially greatly increased the number of prostate cancer diagnoses. Over time, this caused a stage migration, where prostate cancers were more commonly diagnosed at an earlier stage and susceptible to curative therapy. Unfortunately, PSA screening also led to the overdiagnosis and subsequent overtreatment of prostate cancer. Recent trials have shed light on PSA screening, and fueled a heated debate about the use of widespread PSA screening: Is PSA testing causing more harm than good in some patients?7, 8
Physicians now understand that not all prostate cancers are created equally, and in fact some pose little threat to a patient's longevity. Not all of the estimated 217,000 new cases of prostate cancer diagnosed in the US last year9 need immediate, aggressive treatment. Overall prostate cancer incidence has been on the decline since 2000. According to data from the National Cancer Institute, the annual percentage change in prostate cancer incidence from 2000 through 2007 was down 2%.10 Yet Stitzenberg et al found increasing rates of radical prostatectomy over the past decade, despite an apparent decrease in prostate cancer incidence and an evolving understanding that not all localized prostate cancers need immediate, curative treatment. Furthermore, Nationwide Inpatient Sample data corroborate these findings; from 2005 through 2008, there was a 60% increase in the number of hospital discharges after radical prostatectomy.11 Although other explanations for this incongruity (rising numbers of radical prostatectomy despite the decreasing incidence of prostate cancer) are plausible, it is difficult not to suspect that the popularity of robotic surgery has partly driven the increase in prostatectomy volume.
The rapid change in how the majority of prostate cancer surgery is delivered in the US has affected other areas of prostate cancer treatment. Marketing campaigns directed at patients and their families have affected the public's perception of robotic surgery and likely influenced treatment patterns. Urologists commonly see patients actively seeking robotic prostatectomy, when in fact they may be better served with active surveillance or radiation therapy. Market forces influenced many urologists to quickly take up robotic prostatectomy, which resulted in a number of urologists performing the procedure with little prior experience. A study using SEER-Medicare data from 2003 through 2005 found that over half of men undergoing minimally invasive radical prostatectomy had it performed by a surgeon whose annual Medicare volume was fewer than 5 procedures. Furthermore, under 20% of minimally invasive radical prostatectomy, patients had a surgeon whose annual volume was more than 30.2 Stitzenberg et al did not study individual surgeon volume, but their hospital level analysis convincingly demonstrates centralization at higher-volume centers which hopefully will result in improved patient outcomes.
ACCESS TO RADICAL PROSTATECTOMY
A growing body of evidence suggests that centralization of complex surgical procedures such as radical prostatectomy would improve patient outcomes. There is a strong association between volume and outcome; higher-volume surgeons and hospitals tend to have fewer complications and better functional and oncologic outcomes. Patients undergoing robotic radical prostatectomy by higher-volume surgeons tended to have significantly better outcomes and decreased postoperative hospital stays.2
If the popularization of robotic surgery has resulted in increased centralization of radical prostatectomy, this should be a good thing for patients and overall postoperative outcomes should improve over time. However, centralization of prostate cancer care could create unintended barriers and unintentionally limit access to radical prostatectomy for certain populations. Many patients do not have the financial or social means to travel long distances for their health care. Furthermore, centralization may have a negative effect on local health care systems; loss of surgical cases may jeopardize the economic stability of smaller, community hospitals. Stitzenberg et al found that travel distance for their prostatectomy patients increased significantly over the study period. This finding is even more impressive when one considers the context of their study, because it was limited to some of the most densely populated areas within the US (New York, New Jersey, and Pennsylvania). If similar centralization patterns for radical prostatectomy have occurred elsewhere, one would hypothesize that travel distances have increased even more in less populated, more rural areas throughout the central and western regions of the US. As seen in Stitzenberg et al's Figure 4a, surgical robots in the midwestern US can be separated by hundreds of miles.
COST OF RADICAL PROSTATECTOMY
Prostate cancer care is expensive. Approximately $12 billion was spent on prostate cancer care during 2010 in the US and accounted for almost 10% of all cancer care spending.12 If radical prostatectomy accounts for nearly half of all prostate cancer expenditures,13 then widespread changes in surgical approach to prostatectomy may have substantial financial implications. The existing studies comparing the costs of various radical prostatectomy approaches are limited in their scope, and focus only on the costs of the procedure and initial postoperative hospital stay.14-17 These studies found that the cost estimate differences between open and robotic prostatectomy vary substantially and are dependent on the case load. Cost comparisons of prostatectomy approach have consistently yielded higher operative costs of robotic compared with open radical prostatectomy, even when factoring in shorter hospital stays for the robotic patients.14-17 One study found that the median direct cost was more than $2000 higher for robotic prostatectomy compared with open.14 A comprehensive review of the literature found that when including the fixed cost of the robot, the mean cost per robotic prostatectomy was up to $4800 more expensive than its open counterpart.11
Robotic surgery is not solely responsible of the escalating cost of prostate cancer care; other treatment innovations contribute disproportionately to rising costs. A recent study using SEER-Medicare data in which Medicare payments were used as a surrogate for cost, showed that adoption of newer technologies for treating prostate cancer led to substantial increases in the cost of prostate cancer care. Specifically, newer treatment technologies such as intensity-modulated radiation therapy and minimally invasive prostatectomy led to additional Medicare spending of over $350 million in 2005.18 Clearly, more research is needed to further evaluate the cost-effectiveness of robotic prostatectomy and other novel treatments for prostate cancer.
The rapid shift in how the majority of prostatectomies are performed in the US has had collateral effects, affecting the delivery, access, and cost of prostate cancer care. Some of the robotic effects are potentially good, whereas others are potentially not so good.
Stitzenberg et al show convincing data that robotic surgery has potentiated centralization of radical prostatectomy and has likely increased radical prostatectomy case volume. In theory, centralization will result in a greater percentage of patients receiving care from higher-volume surgeons and hospitals. Over time, with complex surgical care concentrated in more experienced hands, functional and oncologic outcomes should improve. If radical prostatectomy quality improves, then downstream treatment costs of postoperative complications, incontinence, erectile dysfunction, and cancer recurrence should all decrease.
However, the cost of prostate cancer care will rise if new treatment technologies inappropriately expand case volume. The data are convincing that the initial procedure costs for robotic surgery are higher than for open surgery. Again, if outcomes improve because of robotic surgery or because of centralization induced by robotic surgery, then the up-front procedure investment in robotics may pay dividends in the future by avoiding costs associated with poor outcomes; this concept deserves further study.
The robot is changing the way prostate cancer care is currently delivered. Presumably, the allure of robotic surgery has siphoned patients away from nonsurgical treatments of prostate cancer and resulted in more patients opting for surgical treatment of their disease than in past years. Centralization of care is not without concerns, because increasing travel distances can limit some patients' access to prostate cancer care. Furthermore, centralization could have a negative effect on local health care systems; loss of case volume may put undue financial strain on community hospitals and physicians, further limiting access to other health services.
Robotic surgery was approved by the US Food and Drug Administration in 2000, and only now are we beginning to understand the effect this technology has had and will continue to have on the field of surgery. More research is needed to further understand how delivery, access, and cost of health care are affected by technological innovation such as the development of robotic surgery.
CONFLICT OF INTEREST DISCLOSURES
The authors made no disclosures.