When are the costs of surgery too great? It’s long been a burning question in prostate cancer, and papers presented over the past few days at the European Association of Urology’s conference in Madrid have added a few more pieces to the risk versus benefits jigsaw.
Speaking recently to Per-Anders Abrahamsson, the association’s Secretary General, for an article to be published in Cancer World, I was told about the current gaping holes in research in prostate cancer. For example, there is no randomised trial comparing radiation therapy with surgery – which constantly gets in the way of good clinical decision-making.
Clinicians and patients are also short of information to weigh about the long-term side effects of treatments – and research presented at EAU showed that the evidence that clinicians currently act on might also be misleading. Take the incidence of erectile dysfunction following prostate removal surgery. The standard way of measuring erectile dysfunction is by the International Index of Erectile Function (IIEF), but researchers from the Herlev Hospital in Copenhagen realised that this might not take into account the sudden change in erectile dysfunction brought about by prostate surgery.
So they added another simple question to the survey: “Is your erectile function as good as before the surgery? (yes/no)”
The difference it made to responses from prostate surgery patients was striking. Responding to the IIEF survey without the additional question, nearly 24% of patients registered no decline in their erectile function after surgery. But when they were asked the additional question, just 7% said their erections were as good as before surgery.
That’s quite a difference for quite a lot of people. Such evidence could have a major influence on decisions about whether or not to have a radical prostatectomy.
Also presented at the conference was evidence about another kind of cost associated with prostate surgery: urinary incontinence. A team of doctors from the University of Nijmegen, the Netherlands, have used health insurance data to reveal the extent of post-operative incontinence and the costs of dealing with it. On a purely financial basis, the information is interesting enough: the average cost of incontinence pads is €210 each year (another study calculated that the 20 year additional cost of incontinence for a man after prostate surgery is close to €50,000).
But more important were the findings about the percentage of men suffering urinary incontinence in the first year after a urology procedure or follow-up. For men undergoing watchful waiting/active surveillance, it was 8%. For those undergoing prostate removal it was 80%, persisting into a second year for 40%.
Patient information about prostate surgery rarely specifies such figures, often offering vague reassurance that “most men” see a quick improvement in continence after surgery – as if it would be wrong to frighten them too much. As more evidence becomes available to fill in the picture on complex decisions, it’s only right that it should be shared with those it affects most.