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Treatments for Gleason 6 at 42 years old

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Posted 5/13/2014 4:57 AM (GMT 0)

I was diagnosed with a small Gleason 6 in December. It was in one core, less than 8%. PSA is between 3.8 and 4.4. I posted on here earlier this year with regard to surgeons, and I appreciated the input. Frankly, however, surgery scares the hell out of me, and I am going to have to live many years (hopefully) dealing with any side effects of treatment.

So I've looked into other things. I would appreciate your thoughts on the options below, particularly if you are around my age and have experience with any of them.

RADIATION

Some folks claim that radiation has lower side effects (on the continence and ED side of things) and is more effective is killing the PC. Even if that's true, it has a risk of secondary cancer (though small), and, more importantly, it leaves the prostate intact. So,  even if the original cancer was taken care of, for the next few decades I have to worry about a new cancer popping up. Because if it does, I can't do surgery and there are very limited treatment options. Doesn't seem like radiation for someone my age makes any sense.

ACTIVE SURVEILLANCE

I certainly qualify for this, but at my age that's a lot of years of AS and a lot of biopsies. And there's no way to be sure that I only have a Gleason 6. There could be a Gleason 7-10 lurking in there. I do AS it will probably only if I do TFT first.

RADICAL PROSTATECTOMY

I have had two excellent surgeons tell me that chance of me being potent after surgery is close to 90%, because of my age. However, they don't have a lot of data to back that up, again because of my age. Also, that percentage means potency, not "back to normal," and it also includes folks who need drugs to get the job done. And then they tell me that I have "insignificant cancer."  They say that Gleason 6 does not become a Gleason 7-10 and does not metastasize. So if I get a Gleason 7-10 in my lifetime, it will be a new cancer, not a more advanced version of my original Gleason 6. Given that, surgery seems like overkill, though I do see the psychological benefit of "getting it out of there."

TFT

I met with the folks at Univ of Colorado. TFT seems like a potential option. It's not RS, but it's not just AS either. They require a mapping biopsy first. They said 2/3 of the patients who have that do not qualify to go on to the actual TFT procedure itself (too much cancer, too aggressive of a cancer, or too many different spots of it). However, I see two potential drawbacks to TFT. One, they told me that I would still require basically the same follow-up as AS, which I was hoping to avoid. They said that would mean even if the TFT is successful I would have biopsies at least every 2 years, if not more often, depending on PSA results. Two, the prostate would still be there and cancer could reoccur. I'm concerned that since I already have a Gleason 6 at age 42, that means I am more susceptible to prostate cancer and have a higher chance than your average Joe of getting it again down the road. And next time it could be a Gleason 7-10. That's one of the questions I have yet to answer. Any thoughts? Of course, after TFT, the full range of treatment options are still available (surgery, radiation, etc).

 

I am having a tough time making this decision. Any input, no matter how small, is appreciated. Thanks.

 

-Jason 

Posted 5/13/2014 5:33 AM (GMT 0)
Jason,

We all have been where you are. My husband was diagnosed in March and we were in shock. Being that I am a nurse by profession, I chose to do all the research so that he didn't have to worry. Like you, my husband is younger. 53 y/o physically fit career army man. Exercise daily and we recently went Vegan prior to his diagnosis. So... we had already set the stage for a better chance at healing just by having all that going for us and didn't know it.

I researched and read articles, I watched videos from surgeons on YOUTUBE, and read medical journal after medical journal. I consulted some friends who were Doctors in the facility I worked... and WE decided DUE TO HIS AGE...that he was physically fit, that we wanted cancer gone the first time, not a guess it was gone with most the other options....We chose a radical prostatectomy via the Da Vinci method here in Richmond Virginia by a Double board certified physician who specialized in ONCOLOGY and UROLOGY. He has performed the most RALP in the state with the highest success rate.

Hubby surgery was on 4/28/14 TEXT BOOK PROCEDURE. He stayed over night in the hospital and left the next afternoon. Sore... and with a catheter in place. Pain averaged from a 0-10 scale at about 5 on bad days and 3 on not so bad days. The catheter was removed on day 10.

ALL PROCEDURES you listed above HAVE SIDE EFFECTS! Nothing is perfect. EVERYTHING takes time to see how it will go. FOR US... we didn't want to risk radiation and not know for sure if it was a hit skip and a miss and not get it all first time around. Removing it...for us,... was a sure bet in our opinion considering it was contained to his prostate.

On day 10 his cath was removed (Not a bad feeling) We expected him to have major issues with urine leakage. Most men you read have to change their pads/depends 4-10 times a day. Considering we started Kegels weeks before surgery, yoga, and pelvic floor exercised to prepare to strengthen those muscles prior to... he has had minimal leakage. He wears a small mens guard (kinda like a panty liner for women) and only needs 1-2 a day. Every day gets a little better.

Also on day 10 post op when the cath was removed, the doc put him on 2.5 mg (LOW DOSE) Cialis. We actuall tried to see if he would respond to stimuli tha same night. HE DID.. Day 1... he was 1/3 hard....day 2 he was 1/2 hard...day 3...3/4 and day 4 he was about 90% and able to achieve and orgasm.

THESE ARE BETTER THAN TYPICAL RESPONCES!

We went into it expecting the worse...and hoping for better.

I have no doubt that the choice we made was the best we could make. ANd the one that seemed to work for us.

Post Edited (Tywife1140) : 5/17/2014 5:07:22 PM (GMT-6)

Posted 5/13/2014 7:03 AM (GMT 0)
Jason,

As you've learned, all the treatment options have the same odds of success, so it is on the side effects that I made my decision.

I like the way you think - especially on the age thing. I agree with you that most people (and surgeons) get it backwards. For me, at 57 and single, I figured I had quite a few good years left of sexual pleasure, and I wasn't ready to give them up. That alone ruled out surgery for me - the chances of lasting ED or even diminished erectile function was just too high. Plus, even the small chance of lasting incontinence, stress incontinence, climacturia and penile shrinkage made me run from the operating room screaming.

A few comments:

Active Surveillance
Active Surveillance programs at tertiary care hospitals involve close monitoring, and typically include a follow-up biopsy within the first year. With an mpMRI used on that biopsy, you can detect any GS≥7 cancer. If the mpMRI is negative, the future biopsy schedule can safely be slowed down. The trend is toward fewer biopsies.

Active surveillance is the only therapy that assures you of complete potency preservation and no urinary issues from treatment.

Radiation
I agree with you that the SEs of radiation are milder and typically transient. I think you painted your analysis of radiation with too broad a brush, however. There are several different ways of doing radiation: SBRT, LDR Brachy, HDR Brachy, Protons (pencil beam and old school), and IGRT/IMRT. All have slightly different SE profiles.

The risk of secondary cancers is quite low. In a study at MSK, surgery, brachy and EBRT all had the same rate of secondary cancers.

Radiation failures can happen for several reasons - hypoxia, cold spots, resistant cancers & metastases. Irradiated prostate cells are thought to be incapable of becoming malignant. Remember that, like surgery for low risk, fewer than 1 in 20 will fail. Most of those will be because the cancer was higher grade than the biopsy revealed and it had already metastasized. For local failures, the best salvage is not surgery, it is more radiation. SBRT and brachy can be used for local salvage.

Surgery
I'm partial to Dr Tewari's torsionless nerve-sparing/penile oxygenation technique, but I agree that it would be nice to see more numbers. You said, "Gleason 6 does not become a Gleason 7-10." This is not known for certain, and if it doesn't, we have seen evidence that G3s can be spawned by the same progenitor cells that spawn Gleason 4s and 5s, so the distinction is immaterial. At any rate, the recurrence rate is identical for adequate radiation and adequate surgery.

Focal Ablation
I agree that for the Low Risk man, there is no advantage to focal therapy over AS. Dr. Emberton, who probably has done more than anyone else, said that the ideal candidate is favorable intermediate risk for whom AS is not an option. As you noticed, recurrence rates are high, and the "index lesion" theory is not proven. Also, there may be risks of healthy tissue injury with thermal ablation, depending on the location of the tumor. There are some exciting new non-thermal techniques in clinical trials. It should definitely only be undertaken with an mpMRI, but that is true of AS as well.

Good luck deciding!
Posted 5/13/2014 10:13 AM (GMT 0)
Jason, in the hands of a great doctor, regardless of treatment, your chances of overcoming side effects is very high. Your chances of a cure, with the numbers you posted above is even greater.

I was two years younger than you when I explored my options and wasn't scared of surgery. I was told that because of my age and level of fitness I would overcome SEs. What I wasn't told is that i'd overcome them immediately. I was dry right off the bat and was having sex the day I was told I could resume. There are many men our age (and older) with similar stories. Under the right circumstances and in the hands of a great surgeon our chances of overcoming SEs are indeed great. From what I've seen the 90%+ chance of overcoming incontinence is indeed accurate in the hands of top guys and I believe ED is in high 80s with these guys.

Given my age I didn't want to consider AS. It was also not something I was comfortable with in general terms although I think it is perfect for my dad who is in his late 60s. Radiation would have been just as effective for me but I was scared of long term side effects caused by the radiation and had no interest int he 40+ sessions. I wanted to take care of it and move on and that is exactly what I did.

Whatever you do, whether AS or surgery or radiation, pick an experienced doctor and benefit from their expertise, there is no substitute for it.

Have you had your slides read by a second lab? I'm one of those guys who went from G6 to G7 upon second reading. I made my decisions when I was still a G6 so it didn't confuse my choices, just my optimism.
Posted 5/13/2014 2:58 PM (GMT 0)
Jason, as you are sadly learning there are no easy answers for men with our disease. However, there are some that would say you don't even have cancer rather a probably indolent lesion that needs watching.

If you are considering continuing with AS you most likely want to get a multi-parametric MRI. That should give you additional info to help in your decision making In fact, there are some who believe that this tool will replace repeat biopsies in AS programs in the future.

None of us can say with certainty what we would do in your exact situation. I can tell you that, most probably, if I had had your stats I would try AS for awhile after getting the above mentioned scan. The reasons for that decision in my own case would be:

1. No side effects.
2. Realization that studies show that if the cancer progresses, treatment will be just as effective then as now.
3. When I was looking at treatment I was doing my best to protect another 30 years of good sex. Of course I wanted the cancer cured but the SE's were a big deal to me
4. Better treatments are "discovered" all the time. AS allows time for those discoveries. For example, when I chose LDR Brachy there was not sufficient data on either TFT or SBRT. Today there is and, while I'm very pleased with my LDR Brachy outcome, I potentially would have chosen one of the other options to give me even better SE odds.

Of course, AS may not be for you but I wanted to give you my perspective as if I had your decision to make.

Good luck.

Jim
Posted 5/13/2014 3:54 PM (GMT 0)
Jason, it's a tough call any way we look at it. I refrain from telling anybody to do what I did. All I will do is share my experience.

I just happened to ask for a PSA on my last physical, at age 58. It was a couple of years since my last one and the doc said he'd do one now that I asked, but the recommendation was not to do it every year. I said we're getting labs anyway, go for it. It came back elevated and he ordered a repeat, which confirmed the first PSA.

I self referred to my urologist and got a biopsy: 6 out of 12 cores bilaterally, Gleason 6 (3+3). I then self referred to uro surgeon. I work here, so I know the docs. My wife and I had pretty much made up our minds when we went to see him, but we all discussed it. He figured 50% involvement, smaller prostate + my good physical condition made me a good candidate for surgery. Surgery doesn't scare me, and he has excellent outcomes. Longevity runs in my family, so the surgery to "get it gone" was the option I took.

Path report upgraded to Gleason 7 (3+4), 50-60% involvement, organ confined. I am fully continent and erections with daily Cialis are becoming more usable for what we want to do. I expect it to improve even further with time.

As with this disease, each of us is different and each of us will have variable outcomes. Get a good doc, do your homework, and make the best decision you can. A crystal ball would be a Godsend, but we don't have any that work. I do not regret my choice. Even on a "down" day, I still do not regret it.

You have joined a reluctant Band of Brothers, but a Band of Brothers nonetheless. Be blessed.
Posted 5/13/2014 4:25 PM (GMT 0)
Jason,
if you were in your 60's AS would be a no brainer, but at 42 it will most likely result in delayed treatment down the road. this is not bad because delayed treatment is just as effective as immediate treatment for low risk patients.
Any of the treatment options will work well in the cancer control area, 95% or higher, so managing the side effects from treatment should be a major concern at your age. Brachytherapy or some form of cyberknife will give you the best chance of avoiding major side effects. Any and all the options are appropriate for someone with your age and stats. the experience and skill of the doctor you choose will influence your treatments much more than the actual option itself.
Posted 5/13/2014 6:38 PM (GMT 0)
Jason,

Being only 42 year old you are, perhaps, not quite old enough to remember the future. When I was a kid we were all about the future. It was all women in short skirts, jet packs, flying cars, stuff made from shiny aluminum, and cures for all diseases, including treatments for prostate cancer that don't make your willy limp and leaky.

Sadly, we've sort of lost track of the future but it's still coming. All the treatment modalities get better every year. You can go to New York and get yourself treated by any of several rockstar surgeons, or to Seattle where some of the best Brachy guys practice, or, if you decide on Active Surveillance, even if treatment is inevitable, you can get that treatment in the future where your options may be better (although I wouldn't count on that jet pack.)
Posted 5/13/2014 7:01 PM (GMT 0)
I'd also consider your current medical coverage vis-a-vis the one the future might hold for you.
Posted 5/13/2014 7:14 PM (GMT 0)
Jason,
AS is getting more and more tests to improve it's safety. You should be aware that the original AS criteria was to biopsy every year but that has been slowed greatly. In fact some protocols call for one confirmatory biopsy after the first year and if no other biomarkers indicate a need then don't biopsy until they do. Here is a list of those newer biomarkers, The link may be best but the diagram shows a lot of potential tools.

urologytimes.modernmedicine.com/print/381097

Remember, Active Surveillance is non-irrevokable. Meaning you can change the path down the road a ways. Treatment is permanent and that bell cannot be un-rung.
Posted 5/13/2014 8:07 PM (GMT 0)
yuck
Posted 5/13/2014 9:01 PM (GMT 0)
Hi Jason,

My comments and circumstances are very similar to Tywife's above. I have access to all the oncology and urology publications and I studied and read everything I could get concerning my particulars, which were 54 years old, a very large prostate, PSA of 7.1 and Gleason 6 @ 10% which was found during TURP late last year. I went to Johns Hopkins for RALP on April 21 and have nearly 100% continence and things are "looking up" in the erection department. For me, I also felt I was, and am, prepared for the worst and am hopeful for the best.

The most important thing, I think, is you do not want to second guess your decision as there are risks with all of your options. There is also some new genomics testing that makes claims to predict how likely your disease will progress based on the genetics of the cancer cells. You may want to look into that to give you some more information to ponder.

Best wishes and good luck with whatever you decide!
Posted 5/13/2014 9:19 PM (GMT 0)
Jason,
Turp's reference to genomics tests is outlined in my link above by specific name so you don't have to search for them. We do know that genetic tests like PCA3, Prolaris, DECIPHER and TMPRSS2:ERG are in fact tests that can stratify higher risk patients. Men who have good scores on these markers seem to do very well and men who do not have higher risk of disease progression.

Post Edited (Tony Crispino) : 5/13/2014 3:23:04 PM (GMT-6)

Posted 5/14/2014 12:54 AM (GMT 0)
Jason,

I was 41 when diagnosed. My initial PSA was 4.6, Biopsy found one of 12 cores positive at gleason 6. I decided to wait a bit while I did some research and got more info from this site. My local urologist recommended A.S., but did state at my age treatment would be necessary at some point. I went for a second opinion, and I was told by a radiation oncologist that if he were me, he would opt for surgery. HIs reason was that a PSA of 4.6 at my age and the small amount of cancer found in the bioposy didn't match up (he thought the cancer was more involved). Turns out he was right. My follow up PSA after the biopsy went to 5.8, I scheduled surgery as soon as I got the PSA result. My post-op pathology report showed a Gleason 7, present in 90% of the slides, and PNI present, which means it was starting to leave the prostate.

side effects have not been bad at all. I am five months post surgery, I have no leakage and do not wear a pad (I stopped after 5 weeks).

I had some ED before surgery (Viagra solved it then), I am beginning to see good progress in getting erections, using the same meds I did before surgery.

Surgery turned out to be my best option....for you, do all the research you can, make sure you get follow up PSA tests, and once you decide what to do...don't look back. No one here will or should tell you what to do, we can only tell our story. I was you just six months ago. I was consumed by "what should I do". I was looking for someone to just tell me what I should do. But ultimately, it is your decision, and after you do all your homework, you will make the right choice.

best of luck
Posted 5/14/2014 12:56 AM (GMT 0)
If I had your numbers and the chance to do it all over again...I would do NOTHING...

More specifically if I were young or old and had a low % Gleason 6 biopsy I would ready myself for a lifetime of AS...The only treatment I would consider would be brachytherapy as I should have when I was treated.

There is no full sexual recovery using any known treatment except AS. Sex will be different if even possible after surgery for sure. My signature says 100%, but that requires a full injection every time for more than 7 years. I am glad I at least have that, but it is not enough...I have avoided the "problems" some others claim with injections... but what if everything still worked right?

I would rather have a lifetime of testing than what I have been forced to endure. I have seen far too many men rush into treatment. I wish I knew then ........what I know now...
Posted 5/14/2014 1:06 AM (GMT 0)

Tony Crispino said...

...... non-irrevokable. Meaning you can change the path down the road a ways. Treatment is permanent and that bell cannot be un-rung.

Seriously?! Revocable. Simple. Lobbyists should use better English.


As a young guy too, 44 now--- 41 at diagnosis, I would have liked to play it out a little before I had to do anything. For me, tho, 2 kids and a bun in the oven at diagnosis, with your almost same numbers, was enough for me to just bite the bullet for open RRP at Hopkins. My guy gave me the same prognosis as what you quoted.

AS, at 41 was never a real consideration. I still don't think it is a real option for any guy my age, but that is just MY opinion. I think AS should be reserved for guys who are nearing their life expectancy, 8-15 years depending on their numbers. Believe me, I've heard and read many stories here how "it" can be "monitored and managed," it's just not for me. You're a young guy with a lot of road in front of you. Be cautious and research AS, not just what "they're" saying now, but what was said a few years ago too.

2.5 years out now and I'm pretty good w/o meds for sex, better with, but that probably would have been the case before treatment too. No continence issues at all. I'm for all intents and purposes back to my former self, but for a 5 inch scar.

My uro/surgeon said to me, "You'll never be as young as you are now and never with greater capacity to recover. You're in good shape and I'm very good at what I do." I trusted him. And as davidg said, the skill of whatever treatment provider you choose will dictate the success of what you choose.

Good luck with your choice.
Posted 5/14/2014 1:21 AM (GMT 0)
You have time and several have given good advise.

I will add that your plan could easily be dictated by your available doctors.

If you had a top 10 doc in both fields... now then you would actually have a decision to make
Posted 5/14/2014 2:22 AM (GMT 0)
"...If you had a top 10 doc in both fields..."

That's a great way to get 12+ differing recommendations in this business. When you say both fields I assume you mean surgery or radiation. But some I know that are considered top ten would say to take your time and see how the disease behaves. Right now it's about cores PSA and Gleason. All favorable to a third option ~ active surveillance.

@Dude...
I like my choice of words. When I was a lobbyist you use terms like that to win favor otherwise if they knew what you were talking about nothing would get passed. Seriously, and I'll let the English scholars say their peace, Surgery is irrevocable. AS is non-irrevocable. I stand by my jibberishness.
Posted 5/14/2014 8:58 AM (GMT 0)
Post removed for Rule #3 violation.

Post Edited By Moderator (Tudpock18) : 5/14/2014 5:26:29 AM (GMT-6)

Posted 5/14/2014 11:45 AM (GMT 0)
I get AS. I really do get it, but it's still a toss of the dice and a spin of the wheel. Give me certainty that the blasted thing won't go rogue and you have my attention. My prostate became my enemy the day my biopsy results came back. Going to war with it was the choice I made.

The recent scandinavian study still shows an edge for treatment, but that will always remain a personal decision. We are stuck with the fact that this cursed disease is different for every single man. No two are the same.

AS at this point can make sense, and we know that treatment options will improve and management of the disease will advance. They're even investigating a vaccine.

No way am I ever going to push somebody into treatment, nor do I want to start another "over treat over react" thread. I think most of us know where we stand on that issue.

However, the brother asked for opinions and he will get them here. We've all paid our membership dues. 6-1/2 hours on an OR table bought me a chair at this table.
Posted 5/14/2014 12:37 PM (GMT 0)
I think AS done properly can be a very effective tool for some men. My personal belief and this is also confirmed by many medical professionals who do not profit from AS, is that it's better suited for an older than a younger man in general terms.

I think telling a man that surgery is irrevocable juxtaposing that statement to slogans about side effects without talking about the details involved with "potential" side effects in different circumstances is no different than telling a man who is considering AS that if he misses the mark he will cross an irrevocable line that could lead to a pretty bad conclusion to his battle with PCa.

Tup, that ok?
Posted 5/14/2014 1:40 PM (GMT 0)
My statement is / was that as a 6 or even a 7 (3+4) you have time. If you are higher (like me unfortunately) you do not have time. You need to act.

My ten cents has consistently been that age and doctors available really are the keystones to a plan. Obviously you need to research and develop a plan and meet with area doctors over the coming months.

At our young ages you are not getting 40+ more years without doing anything...

According to those at Sloane and UPenn when this happens in the young (under 60) it often grows much faster and the younger you are the faster is might grow.
Posted 5/14/2014 2:44 PM (GMT 0)
Most people will find that my perspective mirrors gothicarch's and davidg's. It's very frustrating that this is not a clear cut decision for anybody. Whatever you decide to do, you do it with eyes wide open.

If you are not already registered on Medscape, it's free and you can subscribe to different specialty categories.

This is the Medscape link for the write up on the NEJM article about the latest study from Scandinavia. It's found in the prostate cancer specialty group.

www.medscape.com/viewarticle/821628#1

I can access most of the medical journals from work here and I printed out the entire study from NEJM and gave it to my uro doc. He found it useful.
Posted 5/14/2014 3:57 PM (GMT 0)
"Whatever you decide to do, do it with your eyes wide open..."

Excellent advice. And perhaps the best use of delaying therapy whenever possible. It gives a man time to make educated decisions. I was a 3+4=7 guy at biopsy at age 44 and definitely felt that "get it out, ASAP" pressure. And with my 20 PSA that was the decision we made in 2006. But I was told back then that I did not need to rush to therapy but I did. Given my options in 2006 that was probably the only real choice I had. But I had cores at 90% invaded. There is nothing wrong for a guy today at age 42 deciding in immediate therapy. But a 3+3 guy has new testing options that were not available even two years ago and non-existent when I started out.

I asked my colleagues at ASCO about men having more aggressive prostate cancer in their 40's and the common answer is that we don't know that. There is no study that proves this. Instead we have an era today that will freely screen men in their 40's and we are finding the disease more so in the G6 early G7 ranges. Yes there are more men with higher grades discovered but there are more men with G6's discovered as well.

There is a symposium at ASCO in Chicago on low risk prostate cancer and I look forward to it. It will likely mirror the other symposiums I have attended in the last year. For 2015 the AUA will also announce new guidelines in managing localized prostate cancer with a focus on low risk men. We certainly know what needs to happen with high risk men, but low risk men is a different ballgame. Stratifying age will definitely be a topic on that panel.

Attached is a link to the 2014 NCCN Physicians Guidelines for treating prostate cancer. This is by far the most comprehensive guidelines book to date that I have seen. This is a file attachment as it cannot be linked but I have permission from the NCCN to distribute it from my website. I also have a link in a later post in that thread for the AUA guidelines from 2007. If you take the time to read both you'll see drastic changes over the years on dealing with 40yo men with PCa. Both books are cautious about younger men with low risk disease. The AUA guidelines do not recommend AS for anybody except an old man or men with bad co-midities. I have no doubt that will be addressed in their 2015 version. But the NCCN guidelines are excellent and it shows the option for AS in 40yo men as a delayed therapy approach to better define the tumor behavior.

advancedpcatalk.freeforums.net/thread/81/new-2014-nccn-guidelines

The PCAF site does require an sign in to retrieve documents, but just like signing up for Medscape it's easy to do. This document is a great read for anybody willing to learn it. The patient Handbook is also linked and it's an excellent read as well.

Best of luck on the decision making.
Posted 5/14/2014 4:28 PM (GMT 0)
I advise you listen to Tony for you have no idea how much his views have changed from the 2007 Tony I first met here. If anyone has stayed up with the current state of Pca treatment and non treatment it's him.

Hard to believe we agree 95% of the time now a days Tony. Who would have thunk it? Also let me once again repeat a prime reason for AS is time moves on and my being treated at a cutting edge Pca research center has shown me the possible future of Pca treatment. It's coming and coming soon. Like a political candidate once said back in the 1970s. How would you and your family feel being the last soldier to die in Vietnam? Transposed to be how would you feel to be the last guy to unnecessarily undergo radical surgery and suffer possible lower quality of life side effects? After all there was the last guy somewhere years ago who was the last lobotomy victim.

If I was low risk diagnosed in 2014 instead of 2007 I'd do AS as long as I could until a better option appeared or advanced detection confirms the slow safe PCa turtles from the dangerous hares, for one thing remains constant IMHO you are more likely to die with G6 PCa than of it.
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