It’s complicated for journalists who have to explain data from a systematic review of eight studies comparing three different surgical approaches to endometrial cancer. This story gave an adequate overview. But we would have hoped for a stricter evaluation of the quality of the evidence. And more details on costs.
About 600,000 women will undergo surgical removal of their uterus for a variety of medical reasons. The proliferation of robotic surgery facilities is a trend that demands an analysis of the evidence. Unfortunately there is little chance that we will ever see a randomized controlled trial comparing robot assisted to laparoscopic to open surgery. So we are left with assessing the value of robotic surgery via observational studies. The story speaks to a meta anaylsis of 8 such observational studies of women undergoing surgery for uterine cancer. The study conclusions need to be taken with an understanding of the inherent difficulties associated with observational studies and the statistical methods used. The two independent experts quoted leave somewhat different impressions: one predicting that robotic surgery’s benefits will offset its higher costs; the other commenting on how the surgery wlll be easier but that the outcomes may be similar with or without the robot. Important caveats were used about a surgeon’s learning curve and about finding someone who’s experienced in “minimally-invasive” surgery.
The story only cites the researchers’ statement that the robotic approach adds “a few thousand more dollars to the procedure’s price tag.” But why not give an estimate of actual costs? One surgeon’s definition of a “few thousand” may differ greatly from a patient’s definition. There was also no discusison of whether insurers pay for robotic procedures – another key consideration for readers/consumers.
The story summarized the findings succinctly: the robotic and laparascopic surgeries: “took around the same time and resulted in similarly long stays in the hospital. However, about half as much blood was lost when robots were enlisted than with standard laparoscopy. Both minimally invasive techniques resulted in longer-duration operations than open surgery. But both also led to shorter hospital stays and, in the case of robotic surgery, less blood-loss. Further, the average number of lymph nodes removed was about the same in the robotic and open procedures, suggesting that both approaches result in about equal surgeon accuracy in staging endometrial cancer.”
However, we would have liked to have seen a bit more discussion on the issue of blood loss. Although the amount of blood loss seen in the patients who underwent a robot-assisted procedure was statistically lower, there was no difference in the patients’ need for a transfusion. The 8 studies also had dramatically different blood loss in all three groups. The range of blood loss in patients undergoing a robot-assisted procedure was almost 3 fold (66.6ml in the Veljovich study as compared to 166 in the Bell study).
The story states that “No differences between the three methods were seen in the numbers of complications, report the researchers in the journal Obstetrics & Gynecology.” The researchers reported a very complete breakdown of intraoperative and post-operative complications – including what differences were statistically significant or not. We’ll give the story the benefit of the doubt on this criterion.
The story does include several important provisos in its assessment of the study results. However, we don’t think that it adeqautely describes the methodologic issues associated with the meta analysis. In reality the 8 previous studies were conducted elsewhere with diverse patient populations. Since the studies were observational, it is unclear just how comparable the patiet populations were. For example, patients undergoing an open procedure were older. Age and chronic diseases could have led to the differences seen. An important distinction should have been made concerning blood loss. Although the patients who underwent robot-assisted surgery did, on average, have less blood loss, there was no increase in blood transfusions among the three patient groups. Simply noting less blood loss without speaking to the need for transfusion provides readers with a potentially incomplete view.
There was no disease-mongering of endometrial cancer.
The story quoted two physicians who were not involved in the study.
The entire story was based on a systematic review of studies of three surgical approaches to endometrial cancer. The story did a nice job briefly explaining the differences in the surgical techniques and the differences seen in the study.
The story didn’t include – and it wouldn’t have taken much to do so – any estimate of the number of robotic surgery facilities in the US. And it didn’t give any estimate of how often the open, laparoscopic or robotic procedures are done.
The story states: “Robotic surgery equipment only received U.S. Food and Drug Administration approval in 2005. More research is needed to be able to compare long-term outcomes, wrote the researchers.”
It concludes: “Robotic-assisted surgery is in its infancy, and it definitely has a future,” quoting one physician observer. We’ll give it the benefit of the doubt, although, as we stated in the “Availability” criterion above, we wish it had given more precise estimates of how widespread this “surgery in its infancy” is or is not.
It’s clear that the story did not rely solely on a news release, as it turned to two independent experts.