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Re: Back to the Trench Warfare!! (My New Year's Resolution)

John,

What happened to: "To be continued post festive season!!” You couldn't wait until after New Year's Day? Okay then. I have an early New Year's resolution to introduce.

I will no longer engage in a back-and-forth debate with you henceforth. When I read your rebuttals, I get the impression that you seem to be enjoying this. I do not! I don't know if you get syndicated American reruns in Australia, but this ongoing argument over the fundamental differences in our philosophies reminds me of the old sitcom "All in the Family" with Archie Bunker and Mike Stivic constantly arguing their positions despite the fact that neither one was going to change their thinking based upon what the other had to say. By this time, we have both made our positions very clear to the readers, and to proceed serves no useful purpose other than to tie up the forum with repetitive information and statements.

Now, I realize that what I am saying seems to nullify the following two statements in my last post: "I am not going to let Terry’s old nemesis tear down AS on this forum", and "If you continue to spread "misinformation" about AS, I will do my best to counter it." The reality, though, is that I am not walking away from this. Instead, I am just going to handle it in a more constructive manner. What I mean by that is this: if a reader writes on the subject of AS, I will only address that person directly, even if I am countering what you have to say (and as far as countering your position is concerned, I am very likely to simply refer that reader back to this thread since they can go back into the index, read both sides and decide for themselves. In that way, the everyday reader is spared from having to read through all of that which has been said before).

A good way to start off this new plan is by letting you know that I have no comment on your last post (and believe me, it is not easy for me to say that. I have OCD and, up until now, my nature would compel me to respond when I disagree with something and can back up my position with facts, but as we have seen in this case, that can cause the thread to go on ad nauseam). So, it's a new year (or will be soon enough) and it's time for a new start.

Alan M in the USA

Not Cricket.

We have two old cricket terms in Australia Alan, namely "he took his bat and ball and went home" and "if the cap fit's wear it". I am happy to translate if required.

best wishes for the year ahead to our readers and you to Alan,
john

Re: Not Cricket.

John,

In an effort to be clear on the disagreement we have on this topic it is my understanding that you are OK with AS using the Australian AS protocol. This protocol is very close to what we have in the U.S. Therefore the only real difference you
have with me and others on this forum is your personal view that it should only be used on men with less than 10 years to live. There are no large U.S. medical institutions that have this limitation in their AS protocol currently. So the newly
diagnosed man simply needs to decide if John's view trumps these medical institutions view on AS.

Fred

Some further clarification.

Fred I think we need to clear up some misconceptions here, less I be misrepresented.

I do agree with offering AS to men with a life expectancy of 10 years or less. Surveillance in this circumstance need not be quite so robust.

I have no problem in men with Gleason 6, T1 to T2a, and with a PSA less than 10, being offered AS. However my caveat would be, that the surveillance does indeed need to be active, particularly in younger men. By active I mean, quarterly PSA, six monthly DRE and yearly biopsy and MRI scan. I would consider the following to be trigger mechanisms for active treatment;
- PSA doubling in twelve months or less
- Tumour bulk progression to T2B or greater
- Palpable nodule on DRE
- Asymptomatic patients becoming symptomatic
- Gleason score progression to 3+4, when the pattern 4 component is more than 10% of the pathological review. 4+3 would be an instant trigger.

I express my skepticism re the surveillance being as active as I would like. Wiithout it as some on here have done, AS becomes Russian Roulette.

I also conceded that yearly biopsy does carry the real possibility of sepsis.

I trust my perspective on AS is now clarified.

best wishes,
john

Re: Some further clarification.

John,

So are you saying you are OK with AS in younger men with more than a 10 year life expectancy as long as they follow a strict monitoring protocol, such as you describe, and seek definitive treatment when they break the protocol?

If this is the case, we are in agreement.

Also, if this is the case, I don't understand why you were opposed to Rene's husband considering AS.

Fred

Re: Some further clarification.

Fred I have yielded some ground in relation to AS recently, namely T2A and 3+4 and <10%. I trust the AS disciples on here will acknowledge that concession.

My comments to Rene still stand however, particularly in heeding the fact that PCa tends to be more aggressive in younger men. Rene's husband could have surgery, make a good recovery as most men do, and get on with their lives, or he could stay on AS with the protocol that I have described, the choice is their's. Literature tells us that active treatment will be required at some point, either it will be at a time of Rene and her husband's choosing, or when a trigger has occurred.

best wishes,
john

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