Robot prostate surgery hit by stunning blow
Panel shuns OHIP funding — but five experts disagree
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.