Ro­bot prostate surgery hit by stun­ning blow

Panel shuns OHIP fund­ing — but five ex­perts dis­agree

The Hamilton Spectator - - FRONT PAGE - JOANNA FRKETICH

Ro­botic surgery for prostate can­cer will con­tinue as usual at St. Joseph’s Health­care de­spite con­cerns the prov­ince will aban­don the tech­nol­ogy.

The vast ma­jor­ity of rad­i­cal prosta­te­c­tomy pro­ce­dures done in Hamil­ton use the Da Vinci Si Sur­gi­cal Ro­botic Sys­tem. The min­i­mally in­va­sive surg­eries are par­tially funded by do­na­tions, in­clud­ing a ma­jor gift from the Boris fam­ily who founded Moun­tain Cable­vi­sion.

But the hope that OHIP will even­tu­ally cover the full cost of ro­botic surg­eries was dealt a stun­ning blow in July when the On­tario Health Tech­nol­ogy Ad­vi­sory Com­mit­tee (OHTAC) rec­om­mended against pub­licly fund­ing it.

“It’s some­thing we can’t turn our back on,” said Dr. Anthony Adili, chief of surgery at St. Joseph’s.

“It would be a dis­ser­vice to our pa­tients if we were to aban­don this tech­nol­ogy right now. I think this is the fu­ture for surgery.”

OHTAC, which ad­vises the Min­istry of Health, de­ter­mined there was not enough ev­i­dence that the min­i­mally in­va­sive pro­ce­dure is bet­ter than tra­di­tional open surgery to jus­tify the in­creased price of $6,000 per pa­tient.

Fund­ing the tech­nol­ogy is es­ti­mated to cost the prov­ince an ex­tra $3.4 mil­lion a year.

The rec­om­men­da­tion is so con­tro­ver­sial that five peo­ple rec­og­nized for pro­vid­ing in­put asked to have their names re­moved from the re­port be­cause they dis­agree with the con­clu­sion.

“The sur­gi­cal ro­bot has been around for many years now — close to 15 years — and dur­ing that time the qual­ity of the ev­i­dence that

ex­ists to sup­port its use has not re­ally de­vel­oped well,” said Dr. Ir­fan Dhalla, vice-pres­i­dent, ev­i­dence devel­op­ment and stan­dards for Health Qual­ity On­tario, which con­ducted the as­sess­ment.

He points out the five con­sul­tants were cho­sen to take part be­cause they would be crit­i­cal of the rec­om­men­da­tion so it’s not sur­pris­ing they don’t sup­port it.

“Hun­dreds of thou­sands of pa­tients around the world have had this pro­ce­dure and there has only been one small ran­dom­ized trial — the Aus­tralia study — com­par­ing pa­tients who have had open surgery with pa­tients who have had ro­botic surgery,” said Dhalla.

“I feel like not enough at­ten­tion has been paid to the fact that the man­u­fac­turer of this de­vice has not re­ally sup­ported the ran­dom­ized con­trolled tri­als that would be re­quired to show that ro­bot as­sisted surgery is bet­ter. When those tri­als don’t ex­ist it’s very hard to make a rec­om­men­da­tion in favour of adop­tion.”

St. Joseph’s is al­ready work­ing on stud­ies that will gather both pa­tient and cost data to re­fute the rec­om­men­da­tion.

“I un­der­stand the med­i­cal com­mu­nity has failed a bit in that re­gard,” said Adili. “We have to come to the ta­ble with the data. We want to work with our gov­ern­ment part­ners and OHTAC to say, ‘What data do we need and how do we move for­ward on this?’”

Hamil­ton has a big stake in the re­sult, con­sid­er­ing St. Joseph’s is home to both the Boris Fam­ily Cen­tre for Ro­botic Surgery and the Cen­tre for Min­i­mal Ac­cess Surgery.

“Don’t give it the death knell sen­tence of say­ing, ‘No’ and set us back when we know this tech­nol­ogy is the way for­ward for surgery,” said Adili.

“Hope­fully this will be­come a funded pro­ce­dure. Un­til then, we’re go­ing to con­tinue sup­port­ing our pro­gram and mov­ing it for­ward.

“This is a key strate­gic pro­gram for us at St. Joe’s, for McMaster Univer­sity and for Hamil­ton. We are a pro­vin­cial lead in this area and for our lo­cal com­mu­nity we want to main­tain that pro­vin­cial lead­er­ship.”

The prov­ince is cur­rently re­view­ing the rec­om­men­da­tion.

It can re­ject the ad­vice and fund the tech­nol­ogy that sees a ro­bot at the bed­side hold­ing the in­stru­ments dur­ing surgery in­stead of a doc­tor. The in­stru­ments are in­serted into small in­ci­sions and con­trolled re­motely by the sur­geon.

Na­tion­wide, Al­berta is the only prov­ince with pub­licly funded ro­botic surgery for prostate can­cer.

“The min­istry is com­mit­ted to sup­port­ing in­no­va­tion in On­tario’s health care sys­tem,” the Min­istry of Health said in a state­ment to The Spec­ta­tor Wed­nes­day.

“In par­tic­u­lar, the min­istry un­der­stands hos­pi­tal con­cerns that sup­port is needed to en­cour­age key tech­no­log­i­cal in­no­va­tions in surgery in On­tario in­clud­ing robots, as well as other emerg­ing sur­gi­cal tech­niques.”

A key part of the re­view is un­der­stand­ing how re­cruit­ment, re­ten­tion and train­ing of spe­cial­ists would be af­fected if the prov­ince doesn’t fund the tech­nol­ogy.

“The min­istry is cur­rently con­sult­ing with the chairs of On­tario’s sur­gi­cal train­ing pro­grams to un­der­stand th­ese needs and iden­tify op­por­tu­ni­ties to sup­port in­no­va­tion in this crit­i­cal area of health care.”

Adili says most new urol­o­gists are trained to do ro­botic surgery for rad­i­cal prosta­te­c­tomy and don’t want to work in a hos­pi­tal with­out the tech­nol­ogy.

“For them to go back and do it the way we used to with open surgery it would be very dif­fi­cult, if not im­pos­si­ble to re­cruit a high­cal­i­bre sur­geon,” he said.

De­spite the lack of pub­lished ev­i­dence, sur­geons at St. Joseph’s are con­vinced the tech­nol­ogy is best for pa­tients. In­ci­sions are smaller and they say pa­tients have less blood loss and pain. Men leave hos­pi­tal sooner, said Adili.

“We’re see­ing out­comes that are vastly bet­ter. That is where our frus­tra­tion is. How do we get that data out there?”

It’s not an easy an­swer as many sur­geons in­clud­ing those at St. Joseph’s can no longer eth­i­cally ran­dom­ize pa­tients to the open surgery be­cause they don’t be­lieve it is the best care.

Pa­tients also in­creas­ingly seek out the ro­botic pro­ce­dure and won’t agree to take part in a trial where they could end up hav­ing an open surgery.

“That would have been the way to go in 2001,” said Hamil­ton urol­o­gist Dr. Bobby Shayegan about when the ro­bot de­buted in the United States. “But that ship has sailed a long time ago. It would be al­most im­pos­si­ble to­day to get a trial off the ground with ad­e­quate pa­tient num­bers in a ran­dom­ized fash­ion.”

But with­out that crit­i­cal ev­i­dence, OHTAC is left mak­ing de­ci­sions based on stud­ies with sig­nif­i­cant short­falls.

“The urol­ogy com­mu­nity … feel that those rec­om­men­da­tions are faulty be­cause it’s based on faulty ev­i­dence,” said Shayegan.

“I think it will echo across the coun­try and in our opin­ion it won’t be a nice echo.

“It will set us back in many ways as com­pared to the rest of the world.”

Don’t give it the death knell … hope­fully this will be funded. DR. ANTHONY ADILI

The op­er­at­ing arm of a Da Vinci sur­gi­cal ro­bot.

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