Effects of pathologic stage on the learning curve for radical prostatectomy: evidence that recurrence in organ-confined cancer is largely related to inadequate surgical technique

Abstract

Objectives: We previously demonstrated that there is a learning curve for open radical prostatectomy. We sought to determine whether the effects of the learning curve are modified by pathologic stage.

Methods: The study included 7765 eligible prostate cancer patients treated with open radical prostatectomy by one of 72 surgeons. Surgeon experience was coded as the total number of radical prostatectomies conducted by the surgeon prior to a patient's surgery. Multivariable regression models of survival time were used to evaluate the association between surgeon experience and biochemical recurrence, with adjustment for PSA, stage, and grade. Analyses were conducted separately for patients with organ-confined and locally advanced disease.

Results: Five-year recurrence-free probability for patients with organ-confined disease approached 100% for the most experienced surgeons. Conversely, the learning curve for patients with locally advanced disease reached a plateau at approximately 70%, suggesting that about a third of these patients cannot be cured by surgery alone.

Conclusions: Excellent rates of cancer control for patients with organ-confined disease treated by the most experienced surgeons suggest that the primary reason such patients recur is inadequate surgical technique.

Fig. 1

The learning curve for cancer control after radical prostatectomy, stratified by presence of organ-confined disease. The graph illustrates the predicted probability of freedom of biochemical recurrence (BCR) at 5 yr with increasing surgeon experience. Probabilities are for a patient with typical cancer severity (mean PSA, pathological stage, and grade) within each group. Grey lines, organ-confined disease; black lines, locally advanced disease; dashed lines, 95% CIs.

Fig. 2

Biochemical recurrence after radical prostatectomy. Analysis was restricted to patients with organ-confined disease treated by surgeons with at least 1000 prior surgeries.

Fig. 3

Learning curve for cancer control after radical prostatectomy, stratified by presence of organ-confined disease, in patients treated after 1995 (sensitivity analysis). The graph illustrates the predicted probability of freedom of biochemical recurrence (BCR) at 5 yr with increasing surgeon experience. Probabilities are for a patient with typical cancer severity (mean PSA, pathological stage, and grade) within each group. Grey lines, organ-confined disease; black lines: locally advanced disease; dashed lines, 95% CIs.