I watched the new video from Dr. Myers (http://tinyurl.com/9skrloo), Treating Young Men with Curative Intent.
Quick look synopsis from what I recall:
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Generally, active surveillance for Gleason 7, or above, is not appropriate.
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Do as much as possible to accurately stage the disease (organ confined versus locally advanced). Use endorectal MRI, color Doppler ultrasound, etc. This is to help make a surgery versus radiation decision.
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For organ confined diseased, surgery is best.
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Robotic surgery, with a skilled surgeon, seems to result in fewer complications. But, there is a steep learning curve. Being a good open surgeon does not necessarily translate into being a good robotic surgeon. Some robotic surgeons are getting terrible results. open surgery may be a better option in some regions. Or, travel to get the best robotic surgeon.
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For locally advanced disease (capsule penetration, seminal vesicle invasion, etc) radiation is significantly better than surgery. The radiation field can be extended.
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More controversial is radiating the lymph nodes. He implies it is a good idea for locally advanced situations, but deferred any substantial discussion on the point.
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Experimental therapies, such as HIFU and focal therapy, are “not ready for prime time.”
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Bottom line for young men with G7 or higher: Do all you can to get an accurate picture of the disease and then aggressively treat, choosing the most appropriate therapy given the extent of the disease. He stated, “The first shot you have at aggressive disease is the best one.”