suggesting radical prostatectomy doesn’t beat watchful waiting in terms of overall survival for localised prostate cancer. Surgery can do harm, watchful waiting will not.
This is a development based on the hot of the press study about the impact of robotic prostatectomy centres
It’s a brilliant study and an excellent demonstration of the impact of gizmo idolatry – the Effect of patient choice and hospital competition on service configuration and technology adoption within cancer surgery
It’s NIHR sponsored and open access. Read it for yourself.
commissioner side points that ARENT clear from the study
- There has been large scale adoption between 2010 to 2017. Despite limited to no evidence RAS leads to better long term outcomes. See here and here for example. There’s plenty of others. (there’s good evidence re short term surgical outcome superiority)
- There were 12 centres in 2010 and 42 in 2017, implication 30 robots bought. Approx £2m purchase cost. Let’s assume they were all bought with NHS resources, there may have been some bought with charitable funds. £60m capital cost on a treatment we KNOW doesn’t improve survival or quality of life
- There has been loss of some surgical centres, there are concerns about loss of surgical skills as we switch to robotic assisted. It’s also worth noting there are rumblings of excess harm from RAS. for example see here from Arch Surg. “Conclusions and Relevance During its initial national diffusion, MIRP was associated with diminished perioperative patient safety. To promote safety and protect patients, the processes by which surgical innovations disseminate into clinical practice require refinement.”
- As of 2013 there were approx 4,000 procedures a year, a bit less, but bear with me for the sake of simple maths. In 2013 half of all prostatectomy was robotically assisted, so let’s say 2,000. (I know the number and proportion undertaken by robot assist will have grown considerably since 2013, but again bear with for the sake of simple maths, and assume I’m being conservative)
- And, let’s stick with 2,000 robotic assist prostatectomy procedures per year across 42 centres, simple average of 47 per centre
- At £1,500 uplift in tariff cost per procedure that gives c£3m in additional annual cost compared to laparoscopic procedures.
And that’s assuming laparoscopic prostatectomy does good, see previous blog.
Picking up on point 5 above, might I remind you that the NHSE commissioning policy says RAS will be commissioned from centres performing 150 procedures a year. This was in turn based on NICE Clinical Guideline recommending RAS being cost effective if centres perform 160 procedures a year. That in turn is based on modelled economic data from the HTA picking tumour removal margin and turning that into a proxy for metastatic cancer and then overall survival (remember this HTA predates the RCT which eventually concluded there is no survival advantage between RAS and laparoscopic technique. For those that wish to chase down the HTA – it’s on about p75 or so, I know because I’ve read it.
N= 47 surgical volume destroys any argument about cost effectiveness.
47 procedures per centre is contrary to the commissioning policy and contrary to the NICE recommendation. It doesn’t cut it!
Provider side points
From a provider view, fortune favours the brave. Is teems providers who invest in technology have fared better and grown their business.
Those that didn’t invest risk closure, not due to quality issues but due presumably to the fact men were voting to go to the robot. this will obviously drive providers to want to invest in technology.
But…….Is this a business we actually want to grow?
Read the sentences on implications carefully
“In the absence of appropriate information about quality of care, policies based on patient choice and hospital competition could create incentives for adoption of new technologies without evidence of superior outcomes as hospitals look to retain and attract new patients. The resulting changes in market share for individual hospitals could threaten the viability of their surgical services.”
“Competitive factors, in addition to policies advocating centralisation and the requirement to do minimum numbers of surgical procedures, have contributed to large-scale investment in equipment for robotic surgery without evidence of superior outcomes and contributed to the closure of cancer surgery units. If quality performance and outcome indicators are not available to guide patient choice, these policies could threaten health services’ ability to deliver equitable and affordable cancer care.”
There is then the even murkier business of supply led demand. The excellent editorial alludes to this, but doesn’t go there. presumably the editorialist wants to stick to pure science – applaudable, but the world is messier than science.
“The authors conclude that, in the absence of any other reliable measure of quality or patient experience, patients are attracted by technology, contributing to what they describe as a natural selection process that shapes the market and has, thus far, unconfirmed effects on equity, overall cost, or outcomes”
We know supply induced demand exists, and the mere presence of a “robot” will affect choices men make, especially if the shared decision making context is poor. There’s plenty of evidence on this from the USA. Back to my point about ProtecT – is the robot inducing more men to elect for surgery that would otherwise be well served by watchful waiting.
The editorial picks out a whole host of important and likely never to be answered questions. The reason they won’t be answered is twofold, there’s no incentive to do the research now the adoption is widespread and linked to this – the cat is out of the bag, there’s no going back.
So – my point
it’s a treatment that for many has limited to no impact on quality of life or survival. The largest RCT in history has told us this. It does harm to men. Yet we continue.
We’ve known for some time that the advancement on the standard surgical technique – use of a robot – adds a lot of cost and doesn’t seem to do any additional good, it may be inducing greater harm. We now know that the robot is marching across the country and is probably affecting the choices men make re watchful waiting or surgery (plenty indirect evidence from the USA) – thus causing more harm
From the editorial:
“Are patients misled by high tech and smart marketing by providers investing in it?
And, most importantly perhaps, do patients exerting choice actually lead to better outcomes, and if so, for what type of patient and at what price for the NHS?”
We are doing harm by not assessing this complexity.
We are forcing others to be subject to the opportunity cost.
Is it any wonder why the budget for specialised is continually overspent (ref HSC report, NAO, I could go on). It’s not just a prostate issue, it’s generalised.
Lesson = don’t let it in till full evaluation.
Yes that’s anti innovation (or is it anti invention), but equally it’s pro funding stuff for those that morally bear the brunt of the opportunity cost….. You know, mental health services, general practice, social care, prevention of stuff….things like that
It’s in now, we can’t stop. We spend a lot in this area. For some it does good, for many it does harm…….stop and think about that…..the balance of good and harm in healthcare is rather a delicate thing. We often underplay the harm issue…..
And then we play in cost, and opportunity cost. Opportunity also counts as harm, in terms of what others are denied.
Beyond prostates, see this JAMA piece Estimation of the Acquisition and Operating Costs for Robotic Surgery
STOP AND THINK
The impact of the march of the surgical robot
“The defence will now rest m’laud”