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First, Don, in answer to your question about whose thesis I believe John's analysis supports, I would have to say that, even here, the stats show AS in a favorable light (with even John saying: "So for low risk PCa, our typical AS warrior is on a winner"). That being said, there are not enough men involved in this analysis for the findings to be of any significance. However, it matters not because the large cohorts, like the one posted by Brian Watts, clearly show that AS is an effective strategy for low risk patients yielding outcomes similar to men who underwent immediate treatment. Think about it. As Fred said, there are no large U.S. medical institutions that restrict their AS protocol to older men that are not expected to live 10 more years. So, clearly in the minds of the medical professionals in the know at these medical centers around the country, the scientific evidence on AS has been convincing enough for them to adopt these programs for men with a life expectancy of greater than 10 years. In fact, as I stated earlier, Dr. Patrick Walsh of Johns Hopkins (an highly respected RP surgeon, interestingly enough) does not believe that these men who will likely die in the next decade should even practice AS at all, in the sense of intervening with curative intent if there are signs of progression. Rather, he just recommends observation and points out that these men should not even have had a biopsy in the first place.
Now, on a related note, I would like to thank Fred for the not unexpected, but still disturbing, information on overtreatment released by M.D. Anderson Cancer Center. If there is a positive note in that post, it is the fact that 20% are practicing AS when it wasn't so long ago that, nationally, it was 10%. Slow progress to be sure, with a long, long way to go, but progress just the same. That being said, the number of men with less than 10 years of life expectancy left that are receiving treatment is absolutely shameful and highlights better than any other example I've read of just how absurdly wrong things are in the PCa medical community. It makes me wonder where the disconnect is. That is, we have the major medical institutions mentioned above showing forward thinking by instituting their AS programs, and then you have this black mark on the PCa medical profession. Personally, I believe that the problem lies in the local urologists’ offices and the many run-of-the-mill hospitals and medical centers around the country. It's hard not to be cynical when you read of such data, and with that in mind, it is my opinion that this problem is due to these local doctors and medical institutions being either set in their old-school ways, ignorant (in the sense of not keeping up with the changing times) and/or greedy (since the treatment of PCa is certainly a highly profitable enterprise). Such a long way to go…Sigh!
Lastly, Don, in response to your comment about you not looking for John and I to "re-engage", I have this to say in the vernacular of the good people of Australia (where John resides): "No Worries"… it is not going to happen.
The use of the term "no worries" is a very interesting phenomenon. It is used by Aussies to cover almost every situation, regardless of the circumstances, and regardless of the true extent and nature of the worry. There doesn't have to be an absence of worry for "no worries" to be used. In fact, it is common for "no worries" to be used in the most worrisome of situations.
I just have a simple question or two and likely missed it somewhere along this on-going discussion (which I am not sure the end-game point is); i.e., how does anyone know if they are low risk based on the randomness of biopsies? I have heard that the only way to know full pathology is to examine the gland after it has been reviewed?
Please refer to John Bonneville's response on " some further clarification" dated Dec 27 @ 7:59pm. He does a good job describing an AS monitoring protocol. If you had a high grade tumor that was missed by a needle biopsy and started to grow, your PSA , and imaging testing would catch it.
If you are asking what the end game is in this AS debate, IMO it is recognition, respect, acceptance and implementation among the PCa medical community at large, reflecting the fact that this strategy has proven itself to be a viable option for those that meet the criteria. Until that happens, we are going to continue to have a serious over-treatment problem worldwide.
