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In The News:  Editorial 

First, do no harm

Arnon Krongrad, MD, Miami Herald - Sep, 18 2006

I once asked my grandfather what he thought was important. My grandfather preferred cigarettes to words. He walked away. When I persisted, he let me have it: "That grandma won't have pain." I walked away.

Many years later, I met a patient named David, a young diver who looked invincible before he threw up. David had water on the brain. Tests revealed prostate cancer. When treatment stopped working, David said, "One day I will dive and not come up." I never saw him again.

At about the same time, my friend Larry and I published data showing dietary prevention of cancer with selenium. When he was diagnosed with prostate cancer, he had surgery, radiation, chemo and everything else. Larry died at 50.

We don't prevent prostate cancer, and we do not effectively treat late-stage prostate cancer. We do effectively treat early-stage prostate cancer. However, there's a problem: Treatment is morbid. Consider radical prostatectomy, an operation associated with risk of bleeding, pain, impotence, incontinence, long recovery, heart attack, clots, stroke, infection, injury, scarring and failure to cure. There is risk, discomfort and inconvenience with every prostate cancer treatment.

In Florida, there are approximately 3,500 radical prostatectomies annually. If you conservatively estimate two units of blood for each one, then every year men in Florida receive 7,000 units of blood with radical prostatectomies. Similar conservative estimations suggest 10,000 hospital days, 7,000 units of morphine and other burdens. These numbers represent men in beds, at risk and in pain. We have overwhelming reasons to lighten the burden of treatment.

In 1999, a French colleague approached me at a World Health Organization meeting: He had invented a lighter radical prostatectomy. Overcoming skepticism, within a month I was in his operating room in Paris. My notes and our discussions would form the technical manual for laparoscopic radical prostatectomy (LRP), a minimally invasive form of radical prostatectomy. I came home to Miami with the knowledge I needed.

Then came a God-works-in-mysterious-ways moment. A man named Joe walked into my office, lifted his shirt, and said: "I've been diagnosed with prostate cancer. See these old surgical scars? I am not having surgery. What else do you have?"

For practice, I did two LRPs on pigs at the Miami Metrozoo. Within two weeks, Joe was on the table having LRP. The place was the old Miami Heart Institute. It may have been the wrong place, but it was surely the right time -- time for change.

I left the operating room after eight hours of unrelenting focus. I had a crushing headache, but Joe was fine. He took a couple of Tylenol "just to make her happy" and left the hospital in 48 hours.

This revolution happened seven years ago. Today, after so many more Joes, LRP can take a mere 90 minutes. Almost all men stay only one night. The average inpatient analgesic use is two Tylenols. There is no blood loss - no transfusion in hundreds upon hundreds of cases.

If 3,500 Florida men would annually have surgery with LRP instead of traditional radical prostatectomy, we might see our brothers, fathers and sons save 7,000 hospital days, 7,000 shots of morphine and 7,000 units of blood. Every year.

The deaths of David and Larry caused me deep sorrow. Over time, through encounters with many patients, I absorbed that my grandfather's reluctant philosophy was a practical distillation of the Hippocratic Oath.

Uncertainty is a steady feature of illness. Doctors cannot fix everything, no matter their intellect, passion, training and experience. Still, sometimes better things come along. Sometimes, as in the case of prostate cancer surgery, we can inch a bit closer to "First, do no harm."