One way to identify the best doctors in the country is to watch where public figures go for treatment. After announcing earlier this month that he had prostate cancer, Massachusetts senator and Democratic presidential hopeful John Kerry had the gland removed by Dr. Patrick Walsh of Johns Hopkins University Hospital in Baltimore.
Regarded by many as the best prostate surgeon in the world, Walsh told reporters before the surgery that his new patient had an excellent prognosis: a 97 percent chance of being cancer-free for the next 10 years, a 99 percent chance of avoiding incontinence and a 90 percent chance of retaining full sexual function.
That kind of success was unheard of even 15 years ago, and it's largely a result of Walsh's pioneering of a removal technique that spares nerves near the prune-sized gland, which is just behind the genitals.
But not everyone has access to world-renowned surgeons. Some 220,000 men each year learn they have prostate cancer, and thousands of them make treatment decisions without ever hearing about nerve-sparing surgery. In prostate removal, one slip of the knife can mean a life of impotence. Some surgeons have a proven track record of sparing the nerves; others do not. Many do not provide patients with documented complication rates.
"The result is that patients have only a vague idea of what the risks are," said Dr. Peter Carroll, chief of urology at the University of California, San Francisco. "This is simply not good enough."
In prostate cancer, eliminating the cancer is only the first battle. Most qualified urologists report five-year cure rates of 80 percent or higher, using radiation treatments, surgical removal or a combination. (Some patients also do well with no treatment at all; prostate cancer is often slow-growing and may never spread beyond the gland.)
But the possible complications from treatment are frightening, and highly variable: 1 percent to 7 percent of men end up incontinent; and 20 percent to 80 percent impotent. As a rule, men in their 50s do much better than those in their late 60s or 70s; and those with high blood pressure do worse than those with normal blood pressure.
Yet the surgeon's skill and experience are a big factor. To spare a man's potency, the doctor must separate from the prostate two webbed bundles of nerves that are critical for erection without leaving any prostate tissue behind. Specialists say that doing it well, and reliably, takes training and lots of practice. Many surgeons don't do it often enough to predict their outcomes.
No one knows for sure how to quantify this craft. But the best surgeons tend to do at least one surgery a week, and have been specializing in nerve-sparing procedures for two years or more, urologists say. "A surgeon who's doing at least 50 of them a year can give you an idea of what his rates of complications are," said Dr. Ian Thompson, chief of urology at the University of Texas Health Science Center in San Antonio. "Doing a lot of the surgeries also allows you to continually improve your technique."
Most major cities have at least a dozen specialists in this top category. Generally speaking, for good surgeons, post-surgery rates of incontinence are no higher than 5 percent and rates of impotence no higher than 50 percent. Many men who retain full sexual function require Viagra to do so.
Complication rates of individual surgeons aren't published; there's no way for a prospective patient to get them except from the doctor. "Ask about everything," said Carroll. "You need to sit down with the surgeon and ask directly: How many surgeries do you do a year? What are your complication rates? What are your numbers for men like me? The surgeon has an obligation to provide the answers."
There is no way to know how accurate the numbers are, but when a doctor with a good reputation can provide specific complication rates, it's a very good sign. Some will put the numbers in writing, or pass on the names of previous patients. If the numbers aren't satisfactory, patient advocates urge men to keep looking.
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