Cancer competition drives robot surgery, clinic closures in UK

ENGLAND (Reuters Health) - As more British men are bypassing their local hospital to get prostate cancer surgery farther from home, many treatment centers are closing and many that remain are operating with high-tech robots, a recent study suggests.

“We do not know whether centers adopting new technology offer better quality care,” said study leader Dr. Ajay Aggarwal of the London School of Hygiene and Tropical Medicine.

“A potential concern with this pattern of closures is that some patients will now have to travel further for cancer surgery as a result of closures, which may have an impact on equality in access to cancer surgery given that lower socioeconomic groups and the elderly are less likely to travel for care,” Aggarwal said by email.

Aggarwal’s team examined data from 2010-2014 on 19,256 men in England who underwent radical prostatectomy. They also mapped where men lived and where they received care. Patients were more likely to bypass their local hospital and opt for treatment farther away from home when they got robotic surgery, the study found.

Competition for patients, and men’s choice to travel for care, contributed to a rise in robotic surgery and the closure of several treatment centers, researchers report in Lancet Oncology online October 3.

At the start of the study period, there were 65 centers offering radical prostatectomy, including 12 that performed robotic surgery. By the end, 10 centers had closed, and 39 of the remaining 55 centers, or 71%, offered robotic surgery.

Overall, 23 of the surgery centers that were still open had gained patients during the study period. Ten of these (43%) were established robotic surgery centers.

At the same time, 37 of the still-open centers lost patients during the study, including two that offered robotic surgery. Ten of the centers that lost patients stopped offering radical prostatectomy by the end of the study period.

Radical prostatectomy centers that closed were more likely to be located in areas with stronger competition than in areas with few alternative treatment centers.

No robotic surgery centers closed, regardless of the size of net losses of patients.

One limitation of the study is that researchers used geographic areas rather than specific residential addresses to map how far men lived from the place they went for treatment, the authors note. This may mean the study didn’t accurately reflect whether men bypassed a local hospital to get care in every case.

Furthermore, the researchers couldn’t tell whether men had better outcomes when they chose a surgery center far away, and that’s also a concern, said Dr. Kalipso Chalkidou, author of an accompanying editorial and a researcher at Imperial College London.

“We have no idea whether more and newer is better for each patient who moved to access the high tech,” Chalkidou said by email. “We also don’t know what this wave of new investments has meant for patients who could not or would not move, for patients with other conditions (e.g., heart disease) or for future patients whose taxes or premiums may go up to fund the arms race . . .”

The question of whether men need surgery done by humans or robots also masks the fact that many men also might not need operations at all, Chalkidou noted. Often, men will do fine, and avoid surgical risks like incontinence and impotence, by opting for what’s known as watchful waiting, or periodic screening to make sure tumors aren’t getting worse.

“The evidence is clear that in many cases watchful waiting is a much better option for prostate cancer than intervening,” Chalkidou said.