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Is the cost of robotic-assisted surgery for cancer justifiable?
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Yes.
Robotic surgery tends to be slightly more expensive than open or laparoscopic surgery. However, there are many reasons why the more expensive cost of robotic surgery is justifiable for cancer surgery.
Robotic surgery is much easier to learn than the other two types of surgeries. It is expected people become proficient in any surgery, including robotic, after performing a few. Robotic surgical approach accelerates the pace at which the proficiency is achieved. Robotic platform makes the surgery easier for the surgeon, and it also makes the surgery highly precise and more doable in certain tough situations — adding value to the procedure — especially compared with a minimally invasive approach.
Robotic surgery platform has improved many elements of cancer surgery. For instance, in gynecologic cancers, the robot can help to achieve a high yield of lymph nodes for full dissection and brings a high level of precision to sentinel lymph node dissection, both increasing chances of a better result. In addition, the robotic platform enables earlier discharge because postoperative pain tends to be minimal. The costs saved by the reduction in hospital stays omits the higher costs associated with the procedure.
Many surgeons use the robotic platform for minimal-access surgery. If the robot wasn’t available, a lot of patients would undergo strictly open surgery, which is associated with more blood loss and longer hospital stay, as well as problems that could accrue costs in the long run. In this regard, the straight stick laparoscopy is not a comparable alternative due to the associated steep learning curve with that approach.
One important point is robotic surgery, which has very minimal morbidity and enhances recovery, can make it easier for appropriate patients to receive chemotherapy quickly after surgery, which can positively impact treatment outcome. Data accumulated in multiple specialties suggest that it matters how soon patients can start chemotherapy after surgery, with less optimal outcomes if chemotherapy is delayed. Others would argue you can get the same results with laparoscopy but, again, that is much more difficult to do.
In one gynecologic study of laparoscopy hysterectomy, the conversion rate of straight stick laparoscopy to open surgery was 25%. If you look at the robotic platform, the conversion rate is typically less than 5%, thus leading to a reduction in morbidity and blood loss.
Relatively speaking, the robotic platform is new; it was approved in 2005 by the FDA, so the lifespan of the robot has been no more than 12 years. Another robot is now on the market, Senhance Surgical Robotic System (TransEnterix), and I have no doubt that other robots will follow. The cost of the robot — if higher than another modality — is a temporary problem, because cost is expected to go down substantially in the foreseeable future as more robots enter the market and increase competition. I have no doubt the cost discussion will change and robotic surgical platforms will attract many more surgeons to migrate toward them to the benefit of everyone, especially the patients.
Alexander B. Olawaiye, MD, is associate professor of gynecologic oncology at University of Pittsburgh and Magee-Womens Hospital of UPMC. He can be reached at charleya@upmc.edu. Disclosure: Olawaiye reports no relevant financial disclosures.
No.
When safe and efficacious, a minimally invasive surgical approach should be a priority in oncology care.
Although patient safety and successful outcomes are of paramount importance, cost cannot be ignored. Fortunately, in addition to providing great patient benefit, minimally invasive surgery costs less than similar care using open laparotomy. Although the costs associated with robotic-assisted laparoscopy are generally less than open surgery, most studies demonstrate even greater cost savings when laparoscopic procedures use nonrobotic equipment.
For the additional cost related to robotic-assisted technology and equipment to be justified, it should be associated with patient benefits that are demonstrable and clinically significant. To date, within the field of gynecologic oncology, this is simply not the case. No consistent, clinically significant differences in outcomes have been established between robotic- and nonrobotic-assisted minimally invasive surgery. Yet, the number of institutions investing in robotic surgical devices at great expense continues to rise.
The current dominant robotic surgical platform, da Vinci Surgical System, is an amazing piece of engineering and incorporates several useful technical features: wristed instrumentation, 3-D imaging and tremor reduction. But, these features come with significant expense and have not been shown to improve patient outcomes compared with traditional laparoscopic surgery.
One common argument in favor of the robotic surgical platform focuses on the coincident association between the number of units sold and the increased rate of performance of minimally invasive hysterectomy. Proponents note that the rate of open hysterectomy only began to drop significantly with the introduction of robotics. They contend that nonrobotic laparoscopy was too difficult to perform and that surgeons were, thus, hampered in their ability to provide minimally invasive options for their patients. Although simple and appealing, this argument fails to consider numerous other factors that may have contributed to the rise of the robot.
With the da Vinci’s introduction came an aggressive marketing campaign to surgeons, hospitals and directly to patients. The benefits of the robotic procedures were conflated with laparoscopy in general. Marketing left patients believing that the only way to benefit from a minimally invasive surgery was if it was performed robotically. Surgeons and hospitals were quick to meet patient demands for fear of being seen as “second rate.” Academic conferences were replete with presentations on robotic surgery and surgeons strove to “keep up with” their “progressive” colleagues. Still, studies demonstrated that the benefits of minimally invasive surgery were not exclusive to robotic-assisted surgery, and that uniformly, robotics entailed increased cost.
Minimally invasive surgery, just like open surgery, is challenging to perform. It requires skill, judgement, education, training, practice and, yes, equipment. But expensive robotic devices are not necessary for women with cancer to benefit from minimally invasive surgery. Rather than investing in expensive robotic surgical devices, institutions, training programs and the patients for whom they care would be better served by training and employing surgeons that are capable of providing minimally invasive surgical care without unjustified use of and dependence upon expensive technology. Our patients’ care can and should be both optimal and fiscally responsible.
David M. Boruta II, MD, is chief of gynecologic oncology for Steward Health Care System in Massachusetts. He can be reached at david.boruta@steward.org. Disclosure: Boruta II reports no relevant financial disclosures.