ABSTRACT
BACKGROUND: : Following prostate cancer surgery, positive surgical margin (PSM) status varies among institutions and there is evidence that high-volume surgeons and centres obtain better oncological results. However, larger studies recording PSM for radical prostatectomy (RP) are from large "centres of excellence" and not population-based. Cancer Care Ontario undertook an audit of pathology reports to determine the province-wide PSM rate for pathological stage T2 (pT2) disease prostate cancer and to assess the overall and regional-based PSM rates based on surgical volume to understand gaps in quality of care prior to undertaking quality improvement initiatives. METHODS: : Data were extracted as part of the Pathology Project Audit data output (2005, 2006). Pathology reports were submitted to Cancer Care Ontario by Ontario hospitals electronically via the Pathology Information Management System. An experienced cancer pathology coder extracted the PSM data from eligible RP cancer specimen pathology reports. Only reports that provided a pathological stage were included in the analysis. Biopsy and transurethral resection of the prostate reports were excluded. A convenience sample of 1346 reports from 2006 and 728 from 2005 were analyzed. Regression analysis was performed to assess volume-margin associations. RESULTS: : The median province-wide surgical PSM rate for pT2 disease was 33%, ranging 0-100% among 43 hospitals where RP volumes ranged 12-625. There was no significant correlation (p > 0.05) between volume and PSM by logistic regression with variable odds ratios (95% confidence interval [CI]) for PSM by quartile (1(st) = 1.66 [0.93-2.96]; 2(nd) = 0.97 [0.58-1.62]; 3(rd) = 1.44[0.91-2.29]) compared to the highest volume last quartile. Mean PSM rates between community and teaching hospitals were not significantly different. CONCLUSIONS: : The province-wide PSM rate for pT2 disease prostate cancer undergoing RP is higher than those published from "centres of excellence." Results from larger volume centres were not statistically significantly better, which contradicts previously published data. Factors, such as individual surgeon, patient selection, pathological processing and interpretation, may explain the differences.
ABSTRACT
BACKGROUND: The objective is to provide surgical and pathological guidelines for radical prostatectomy (RP) with or without concurrent pelvic lymph node dissection (PLND) to achieve optimal benefit for patients, with minimal risk of harm. METHODS: For surgical questions, a literature search of MEDLINE, EMBASE and the Cochrane database was performed. A literature search for the pathological questions was not conducted since the protocol for invasive carcinomas of the prostate gland developed by the College of American Pathologists (CAP) was endorsed. Urologists and pathologists were consulted for their assessment of the surgical and pathological recommendations. RESULTS: Limited high-quality evidence from 95 primary studies was available and, therefore, the expert panel developed recommendations on the basis of a consensus of the expert opinion of the working group and through a consultation with urologists and pathologists. In addition to the CAP protocol, some technical recommendations related to the handling and processing of the specimen were made. CONCLUSION: Radical prostatectomy is recommended for the surgical treatment of prostate cancer, depending on a patient's preoperative risk profile. The panel unanimously determined that the goals for RP are to attain a positive margin rate of <25% for pT2 disease, a mortality rate of <1%, rates of rectal injury of <1% and blood transfusion rates of <10% in non-anemic patients. Standard PLND should be mandatory in high-risk patients, should be recommended for intermediate-risk patients and should be optional for low-risk patients. The quality and effectiveness of this treatment and of subsequent patient care depend on good management, effective communication and reporting between surgeons and pathologists working together as part of a multidisciplinary team. The complete guideline document is posted on the Cancer Care Ontario website (www.cancercare.on.ca); search in their Toolbox, Quality Guidelines & Standards, Clinical Program category under "surgery."
