Should my accountant sing La Traviata at the Met?

The request for this Point / Counterpoint was received on Sept. 6, 2007. It was also the day that Italian opera star Luciano Pavarotti died at the age of 71 from advanced pancreatic cancer. One year earlier, Pavarotti had developed resectable pancreatic cancer and underwent a pancreaticoduodenectomy, or Whipple resection, in New York. Why did he have his surgery in New York? Well, Pavarotti was a well-informed man and was aware of evidence that surgical morbidity and mortality are markedly better if this operation is done in a larger volume centre that has appropriate surgical expertise and postoperative support. As part of the evidence-driven movement to improve quality and safety of patient care, leaders within surgical oncology argue appropriately that complex oncological surgery should be restricted to highly trained surgical oncologists in larger academic centres. While the evidence is probably best in hepatobiliary surgery, there are similar data for some of the more difficult urological surgical procedures, such as cystectomy and retroperitoneal lymph node dissection. We suspect that if any of the CUAJ readers were to develop a resectable urological cancer, they would seek to have their operation performed by the best surgeon in a centre with first-rate postoperative care. Given the importance of training, expertise and appropriate supportive care is so clearly understood by surgical oncologists, it is curious that some leaders in urological surgery would then throw these principles out the window and suggest that urologists be able to order chemotherapy. As medical oncologists rather than psychiatrists, we are not properly trained to comment on the cognitive processes that might lead intelligent and otherwise rational individuals to take such a point of view. Rather, we will indicate why it is not appropriate for urologists to deliver systemic therapy. Surgery is the oldest treatment modality for cancer and the majority of patients who survive their cancers do so because of surgical resection of the primary. Medical oncology is a much younger specialty, born in the aftermath of World War II when drugs like nitrogen mustard were used to treat malignant lymphoma. It is now approaching middle age and 2008 represents the 35th anniversary of the formal recognition of medical oncology as a subspecialty by the American Board of Internal Medicine. It is a rapidly evolving field, moving from the empirical toward tailored treatment. Some notable achievements came in the late 1970s when effective treatment with combined systemic chemotherapy was developed for advanced testicular cancer. The regimens developed, improved and evaluated by medical oncologists over the following 2 decades assured constantly improving care such that most patients with advanced disease are now cured. Such treatment is complex, and among medical oncologists it is recognized that patients with testicular cancer should be treated by those with experience and expertise. Is it possible that urologists could achieve similar results if they were to treat testicular cancer patients with chemotherapy? We do not need clinical trials to answer this question. The relation between potential for cure and serious toxicity is finely balanced and at least equivalent to that associated with a major operation; it requires comparable training and experience. Similar logic applies to chemotherapy used for other urological cancers. From the perspective of quality of care and patient safety, only a medical oncologist with appropriate training and expertise in the systemic treatment of early and advanced urological cancer can give the best possible care to these patients. Physicians and surgeons benefit both themselves and their patients if they are self-critical, recognize their own limitations and allow those who are best qualified to treat the patient to do so. What is best for the patient should always be given priority over what is best for the doctor. Patient safety is the dominant factor. A urological oncologist and a medical or radiation oncologist trained in urological cancer should understand when surgery, radiation therapy and chemotherapy are appropriate Should my accountant sing La Traviata at the Met?