Behavioural queueing : cellular automata and a laboratory experiment

Dans cette thèse, nous étudions les aspects comportementaux d'agents qui interagissent dans des systèmes de files d'attente à l'aide de modèles de simulation et de méthodologies expérimentales. Chaque période les clients doivent choisir un prestataire de servivce. L'objectif est d'analyser l'impact des décisions des clients et des prestataires sur la formation des files d'attente. Dans un premier cas nous considérons des clients ayant un certain degré d'aversion au risque. Sur la base de leur perception de l'attente moyenne et de la variabilité de cette attente, ils forment une estimation de la limite supérieure de l'attente chez chacun des prestataires. Chaque période, ils choisissent le prestataire pour lequel cette estimation est la plus basse. Nos résultats indiquent qu'il n'y a pas de relation monotone entre le degré d'aversion au risque et la performance globale. En effet, une population de clients ayant un degré d'aversion au risque intermédiaire encoure généralement une attente moyenne plus élevée qu'une population d'agents indifférents au risque ou très averses au risque. Ensuite, nous incorporons les décisions des prestataires en leur permettant d'ajuster leur capacité de service sur la base de leur perception de la fréquence moyenne d'arrivées. Les résultats montrent que le comportement des clients et les décisions des prestataires présentent une forte "dépendance au sentier". En outre, nous montrons que les décisions des prestataires font converger l'attente moyenne pondérée vers l'attente de référence du marché. Finalement, une expérience de laboratoire dans laquelle des sujets jouent le rôle de prestataire de service nous a permis de conclure que les délais d'installation et de démantèlement de capacité affectent de manière significative la performance et les décisions des sujets. En particulier, les décisions du prestataire, sont influencées par ses commandes en carnet, sa capacité de service actuellement disponible et les décisions d'ajustement de capacité qu'il a prises, mais pas encore implémentées. - Queuing is a fact of life that we witness daily. We all have had the experience of waiting in line for some reason and we also know that it is an annoying situation. As the adage says "time is money"; this is perhaps the best way of stating what queuing problems mean for customers. Human beings are not very tolerant, but they are even less so when having to wait in line for service. Banks, roads, post offices and restaurants are just some examples where people must wait for service. Studies of queuing phenomena have typically addressed the optimisation of performance measures (e.g. average waiting time, queue length and server utilisation rates) and the analysis of equilibrium solutions. The individual behaviour of the agents involved in queueing systems and their decision making process have received little attention. Although this work has been useful to improve the efficiency of many queueing systems, or to design new processes in social and physical systems, it has only provided us with a limited ability to explain the behaviour observed in many real queues. In this dissertation we differ from this traditional research by analysing how the agents involved in the system make decisions instead of focusing on optimising performance measures or analysing an equilibrium solution. This dissertation builds on and extends the framework proposed by van Ackere and Larsen (2004) and van Ackere et al. (2010). We focus on studying behavioural aspects in queueing systems and incorporate this still underdeveloped framework into the operations management field. In the first chapter of this thesis we provide a general introduction to the area, as well as an overview of the results. In Chapters 2 and 3, we use Cellular Automata (CA) to model service systems where captive interacting customers must decide each period which facility to join for service. They base this decision on their expectations of sojourn times. Each period, customers use new information (their most recent experience and that of their best performing neighbour) to form expectations of sojourn time at the different facilities. Customers update their expectations using an adaptive expectations process to combine their memory and their new information. We label "conservative" those customers who give more weight to their memory than to the xiv Summary new information. In contrast, when they give more weight to new information, we call them "reactive". In Chapter 2, we consider customers with different degree of risk-aversion who take into account uncertainty. They choose which facility to join based on an estimated upper-bound of the sojourn time which they compute using their perceptions of the average sojourn time and the level of uncertainty. We assume the same exogenous service capacity for all facilities, which remains constant throughout. We first analyse the collective behaviour generated by the customers' decisions. We show that the system achieves low weighted average sojourn times when the collective behaviour results in neighbourhoods of customers loyal to a facility and the customers are approximately equally split among all facilities. The lowest weighted average sojourn time is achieved when exactly the same number of customers patronises each facility, implying that they do not wish to switch facility. In this case, the system has achieved the Nash equilibrium. We show that there is a non-monotonic relationship between the degree of risk-aversion and system performance. Customers with an intermediate degree of riskaversion typically achieve higher sojourn times; in particular they rarely achieve the Nash equilibrium. Risk-neutral customers have the highest probability of achieving the Nash Equilibrium. Chapter 3 considers a service system similar to the previous one but with risk-neutral customers, and relaxes the assumption of exogenous service rates. In this sense, we model a queueing system with endogenous service rates by enabling managers to adjust the service capacity of the facilities. We assume that managers do so based on their perceptions of the arrival rates and use the same principle of adaptive expectations to model these perceptions. We consider service systems in which the managers' decisions take time to be implemented. Managers are characterised by a profile which is determined by the speed at which they update their perceptions, the speed at which they take decisions, and how coherent they are when accounting for their previous decisions still to be implemented when taking their next decision. We find that the managers' decisions exhibit a strong path-dependence: owing to the initial conditions of the model, the facilities of managers with identical profiles can evolve completely differently. In some cases the system becomes "locked-in" into a monopoly or duopoly situation. The competition between managers causes the weighted average sojourn time of the system to converge to the exogenous benchmark value which they use to estimate their desired capacity. Concerning the managers' profile, we found that the more conservative Summary xv a manager is regarding new information, the larger the market share his facility achieves. Additionally, the faster he takes decisions, the higher the probability that he achieves a monopoly position. In Chapter 4 we consider a one-server queueing system with non-captive customers. We carry out an experiment aimed at analysing the way human subjects, taking on the role of the manager, take decisions in a laboratory regarding the capacity of a service facility. We adapt the model proposed by van Ackere et al (2010). This model relaxes the assumption of a captive market and allows current customers to decide whether or not to use the facility. Additionally the facility also has potential customers who currently do not patronise it, but might consider doing so in the future. We identify three groups of subjects whose decisions cause similar behavioural patterns. These groups are labelled: gradual investors, lumpy investors, and random investor. Using an autocorrelation analysis of the subjects' decisions, we illustrate that these decisions are positively correlated to the decisions taken one period early. Subsequently we formulate a heuristic to model the decision rule considered by subjects in the laboratory. We found that this decision rule fits very well for those subjects who gradually adjust capacity, but it does not capture the behaviour of the subjects of the other two groups. In Chapter 5 we summarise the results and provide suggestions for further work. Our main contribution is the use of simulation and experimental methodologies to explain the collective behaviour generated by customers' and managers' decisions in queueing systems as well as the analysis of the individual behaviour of these agents. In this way, we differ from the typical literature related to queueing systems which focuses on optimising performance measures and the analysis of equilibrium solutions. Our work can be seen as a first step towards understanding the interaction between customer behaviour and the capacity adjustment process in queueing systems. This framework is still in its early stages and accordingly there is a large potential for further work that spans several research topics. Interesting extensions to this work include incorporating other characteristics of queueing systems which affect the customers' experience (e.g. balking, reneging and jockeying); providing customers and managers with additional information to take their decisions (e.g. service price, quality, customers' profile); analysing different decision rules and studying other characteristics which determine the profile of customers and managers.

Appropriate maintenance treatment for Crohn's disease: results of a multidisciplinary international expert panel - EPACT II

Introduction: Biological. therapy has dramatically changed management of Crohn's disease (CD). New data have confirmed the benefit and relative long-term safety of anti-TNF alpha inhibition as part of a regular scheduled administration programme. The EPACT appropriateness criteria for maintenance treatment after medically-induced remission (MIR) or surgically-induced remission (SIR) of CD thus required updating. Methods: A multidisciplinary international expert panel (EPACT II, Geneva, Switzerland) discussed and anonymously rated detailed, explicit clinical indications based on evidence in the literature and personal expertise. Median ratings (on a 9-point scale) were stratified into three assessment categories: appropriate (7-9), uncertain (4-6 and/or disagreement) and inappropriate (1-3). Experts ranked appropriate medication according to their own clinical practice, without any consideration of cost. Results: Three hundred and ninety-two specific indications for maintenance treatment of CD were rated (200 for MIR and 192 for SIR). Azathioprine, methotrexate and/or anti-TNF alpha antibodies were considered appropriate in 42 indications, corresponding to 68% of all appropriate interventions (97% of MIR and 39% of SIR). The remaining appropriate interventions consisted of mesalazine and a "wait-and-see" strategy. Factors that influenced the panel's voting were patient characteristics and outcome of previous treatment. Results favour use of anti-TNF alpha agents after failure of any immunosuppressive therapy, while earlier primary use remains controversial. Conclusion: Detailed explicit appropriateness criteria (EPACT) have been updated for maintenance treatment of CD. New expert recommendations for use of the classic immunosuppressors as well as anti-TNF alpha agents are now freely available online (www.epact.ch). The validity of these criteria should now be tested by prospective evaluation. (C) 2009 European Crohn's and Colitis Organisation. Published by Elsevier B.V. All rights reserved.

Lecture d'articles médicaux: quelques pièges à éviter [Reading medical articles--what pitfalls to avoid]

Critical reading and careful interpretation of results of the medical literature is a difficult task for primary care physicians. Being aware of common potential pitfalls that may bias results of a study is helpful. Among common pitfalls, odds ratios are often interpreted as relative risks, which overestimate the impact of a risk factor. Randomized controlled trials assessing the effectiveness of a new drug or a new target disease often use surrogate markers instead of clinical events as outcomes. Results of these trials should be considered with caution before using their results for clinical practice. For screening, observational studies often yield potentially biased or conflicting results. As clinical guidelines and expert opinions are often conflicting, primary care physicians should wait for results of large clinical trials in clinical events before changing their practice for screening or new drugs.

Should Koos grade I vestibular schwannomas be treated early with gamma knife surgery? A subgroup analysis in a series of 190 consecutive patients.

INTRODUCTION: Gamma knife surgery (GKS) for vestibular schwannomas (VS) has a long-term clinical and scientific track record. After a period of de-escalation of dose prescription, results show a high rate of tumor control with improvement of clinical outcome (less than 1% facial palsy, 50-70% hearing preservation). Régis et al. (J Neurosurg 2013;119 Suppl.:105-11) suggested recently that proactive GKS management in intracanalicular tumors is better than a « wait and see » strategy when hearing is still useful at the time of diagnosis. MATERIALS AND METHODS: Based on these previous findings, we prospectively analyzed 190 vestibular schwannomas (VS), treated with GKS as first intention over a period of 4 years (2010-2014). We concentrated on patient, tumor and dosimetric characteristics. Special attention was given on the dose to the cochlea and its impact in maintaining serviceable hearing. RESULTS: The mean follow-up period was 1.3years (range 0.6-3.6). Preoperative serviceable hearing was present in 63.11% patients. The mean maximal diameter was 15.1mm (range 5-29.5). The size and volume of the tumor corresponded to Koos grade I, II, III and IV in 15.9%, 34.8%, 45.4% and 3.8% of the cases, respectively. The mean target volume was 1.24cm(3) (0.017-7.8). The mean prescription isodose volume was 1.6 cc (0.032-8.5). The mean marginal dose was 12Gy (11-12). The mean maximal dose received by the cochlea in patients with GR class 1 and 2 was 4.1Gy (1.5-7.6). Our preliminary neuroradiological follow-up shows 97% tumor control, with 45% shrinkage. Patients presenting with GR class 1 and class 2 at baseline retained serviceable hearing in 85% of cases. Among the patients with a follow-up of at least one year, those with Koos I tumors had the highest probability to maintain identical level of hearing after GKS. CONCLUSION: Our preliminary data suggest that Koos I patients should be treated early with GKS, before tumor growth and/or hearing deterioration, as they have the highest probability of hearing preservation.

Enzymes musculaires et exercice physique [Muscle enzyme activity and exercise]

Exercise is classically associated with muscular soreness, presenting one to two days later, delayed onset muscular soreness. Blood muscle enzymes and protein elevations are characteristic, and may cause renal failure. Creatin phosphokinase peak appears on the fourth day and depends on exercise type and individual parameters. This effect is attenuated with repeated bouts, by habituation. Metabolic complications are rare. The knowledge of this reaction, even with common exercises, allows to postpone investigations for a complex metabolic disorder, or to avoid stopping a medication for fear of a side effect, as with statins. Indeed, it is necessary to wait for seven days without any exercise before interpreting an elevated CK result.

Evaluation of existing technologies in manufacturing of decorative solutions

Matkapuhelinvalmistajien välinen kilpailu kiristyy jatkuvasti. Tuotteiden ollessa teknisiltä ominaisuuksiltaan lähes samanvertaisia, asiakkaat alkavat kiinnittää huomiota myös puhelimen muihin ominaisuuksiin.Puhelimen koristeellisuudesta ja mandollisuudesta personoida matkapuhelin, on muodostumassa entistä tärkeämpiä tekijöitä puhelinvalmistajien välisessä kilpailussa. Asiakas ei myöskään ole valmis odottamaan puhelintaan, vaan haluaa puhelimensa nopesti. Lyhyt läpimenoaika on puhelinvalmistajille elintärkeä kilpailutekijä. Tämän työn tehtävänä on tutkija puhelinvalmistajien alihankkijan teknologisiamandollisuuksia laajentaa tuotevalikoimaansa vastaamaan tämän päivän tarpeita koristella matkaviestimiä. Teknologioioden sovellukset, Tuotantokustannukset, läpimenoajat ja teknologoiden riskit ovat tutkimuksen pääkohteet. Tavoitteena on saavuttaa käsitys kohdeyrityksen mandollisuuksista vastata asiakkaansa tarpeisiin olemassa olevilla teknologioilla ja niiden kombinaatioililla.

Tilaus- toimitusprosessin kehittäminen tilausohjautuvassa tuotannossa

Diplomityön tavoitteena on tilaus- toimitusprosessin kehittäminen tilausohjautuvassa tuotannossa. Prosessin nykytilan tarkemman analysoinnin avulla on tarkoitus lisätä prosessissa työskentelevien henkilöiden käsitystä siitä, miten prosessi toimii tällä hetkellä sekä minkälaisesta liiketoiminnasta onkaan kyse. Tämä työ on osa laajempaa kohdeyrityksessä meneillään olevaa kehitysprojektia, jonka päätöksentekoa on tarkoitus tukea tässä työssä tehtyjen analyysien avulla.Työ on jakautunut kolmeen osaan; teoria-, analyysi- sekä synteesiosaan. Teoriaosassa käsitellään prosesseja yleisesti, niiden kehittämistä sekä mittaamista. Prosessien kehittämismenetelmistä esitellään kapeikkoajattelu sekä Lean-tuotanto. Analyysiosassa käsitellään tilastollistenanalyysien perusteella prosessin nykytilaa ja liiketoiminnan luonnetta. Pilottitoimitus sekä laajemman kehitysprojektin esittely kuuluvat myös analyysiosan sisältöön. Analyysiosan perusteella tuotteiden läpimenoaikaa voidaan lyhentää vähentämällä eri vaiheiden välisiä odotusaikoja. Myös materiaalien saatavuus tulisi varmistaa kehittämällä tavaralogistiikkaa. Synteesiosassa on listattu käytännönläheisiä kehitysehdotuksia prosessin suorituskyvyn parantamiseksi. Pohjana ehdotuksille on analyysiosassa ilmenneet ongelmat. Laajempana kehityskohteena esitellään kolmivaiheinen muutosprosessi, jonka avulla voidaan tehostaa tavaralogistiikkaa ulkoistamisen avulla.

Liikevaihdon ja materiaalivirtojen kasvun vaatimukset logistiikkakeskukselle

Incap Furniture Oy on koottavien mäntyhuonekalujen sopimusvalmistaja. Yrityksen tavoitteena on saavuttaa 70 miljoonan euron liikevaihto Kärsämäen tehtaalla vuonna 2008. Suurin osa komponenttituotannosta ostetaan alihankintaverkostosta ja valmiit tuotteet pakataan logistiikkakeskuksessa. Diplomityön tavoitteena oli selvittää miten kasvavat materiaalivirrat saadaan tulevaisuudessa käsiteltyä Kärsämäen tehtaan logistiikkakeskuksessa Työn teoriaosassa on ensin käsitelty mahdollisuuksia vähentää kokoonpanon puutetilanteita ostotoimintaa kehittämällä. Teoriaosassa esitellään lisäksi varastonohjausmenetelmiä, sekä yleisesti varastoinnin tehtäväkenttää. Empiirisessä osassa analysoitiin annettujen tietojen avulla vuoden 2008 tavoitetilaa, sekä simuloitiin tavoitetilan materiaalivirtoja suhteessa logistiikkakeskuksen kapasiteettiin. Kasvavat materiaalivirrat pakottavat kehittämään logistiikkakeskuksen toimintaa. Eräluonteisen toiminnan vuoksi kaikkien komponenttien kohdalla on pyrittävä MRP ohjaukseen. Komponenttientilauseriä on pyrittävä pienentämään vastaamaan todellista tarvetta. Kriittisille A- ja B- komponenteille tarvitaan lisäksi puskurivarastot tasaamaan toimitusajan vaihtelua ulkomaantoimituksissa. Pakkauseristä yli jäävät C nimikkeet tulee varastoida jatkossa erillään logistiikkakeskuksesta ja korkeavarastosta. D- ja E-nimikkeitä ei kannata tuoda ulkomailta, eikä niitä ole kannattavaa varastoida lainkaan. Pakkaamon täytyy toimia tulevaisuudessa kolmessa vuorossa ja korkeavaraston työjonoa on lyhennettävä kolmesta vuorokaudesta 4-6 työvuoroon. Edellä mainituilla toimenpiteillä ja toimitusten aktiivisella seurannalla saavutetaan toimintaympäristö, jolloin logistiikkakeskuksen kapasiteetti riittää materiaalivirtojen kasvaessa.

Verkkonaapuruston valvontatehtävien siirto mobiililaitteelta kiinteälle laitteelle PeerHood -verkossa

PeerHood -verkon mobiililaitteiden akkutehon säästämiseksi siirretään mobiililaitteen verkkonaapuruston valvontatehtävät kiinteälle laitteelle. Valvontatehtävien siirto on tarkoitus tehdä silloin, kun laite pysyy paikallaan, esimerkiksi toimisto tiloissa. Laitteen pysyessä paikallaan voidaan verkkonaapurustoa seurata kiinteän laitteen resursseilla ja päivittää verkkomuutokset mobiililaitteelle tarvittaessa. Mobiililaitteen ollessa vain kuuntelutilassa laite säästää akkutehoa, koska sen ei tarvitse aktiivisesti lähettää dataa verkkolaitteillaan. Verkkolaitteet pysyvät lepotilassa ja odottavat vain tulevaa dataa. Verkkonaapuruston valvontatehtävien siirto ei kuitenkaan vaikuta käyttäjän palveluiden hyödyntämiseen, joten verkkolaitteen akkutehon säästö riippuu suuresti käyttäjän toimista, käyttäjä voi edelleen käyttää muiden PeerHood laitteiden palveluita tai tarjota omiaan.

Piikarbidipuolijohdekomponentit tehoelektroniikassa

Piikarbidi (SiC) on tunnettu korkealuokkaisena hioma-aineena ja hiekkapaperin pin-noitteena yli 100 vuoden ajan. Nykyisin ainetta käytetään pääasiassa puolijohteiden raaka-aineena. Piikarbidi on puolijohteena ylivoimainen tavanomaiseen piihin (Si) verrattuna lähes joka suhteessa johtuen sen kiderakenteesta, mutta sen valmistus on osoittautunut erittäin monimutkaiseksi johtuen pääasiassa vaikeudesta kasvattaa riittävän suuria ja laadukkaita SiC-kiteitä. Siksi tehoelektroniikan SiC-puolijohdekomponenttien laajamittaista käyttöä joudutaan yhä odottamaan. Tässä diplomityössä tehdään perusteellinen selvitys, miten piikarbidin valmistuspro-sessit eroavat normaaleista piin valmistusprosesseista, mitä etuja piikarbidin käytöllä saavutetaan ja vastaavasti mitä varjopuolia sillä on. Työssä selvitetään tällä hetkellä markkinoilla olevien SiC-tehopuolijohdekomponenttien ominaisuuksia, ketkä ovat teh-neet tutkimusta alalla, sekä esitetään arvioita SiC-tekniikan tulevaisuuden näkymistä.

Hankintatoimen toimittaja-arviointijärjestelmän kehittäminen auditoinnin avulla: Case Valio Oy

Pro gradu –tutkielman aiheena on hankintatoimen toimittaja-arviointijärjestelmän kehittäminen auditoinnin avulla. Työn päätavoitteena on toimittaja-arviointijärjestelmän kehittäminen case-yrityksen nykyisille toimittajille yrityksen tärkeinä pitämät näkökohdat huomioiden. Tutkimus on tyypiltään laadullinen tutkimus. Aineisto on kerätty kirjallisuuteen perehtymällä, haastatteluilla ja havainnoiden. Arviointikriteerit sisältöineen on valittu teorian ja yrityksessä tehtyjen haastattelujen pohjalta. Tutkimuksen lopputuloksena syntynyt arviointilomake mahdollistaa toimittajien keskinäisen vertailun. Arviointitekniikkana on käytetty auditointia. Arviointilomaketta on testattu muutamilla tavarantoimittajilla. Arvioinnin avulla on tunnistettu parhaimpia toimittajia ja löydetty kehittämistä vaativia osa-alueita samoin kuin heikompia toimittajia. Arviointilomakkeeseen mukaan otettu pisteytys on mahdollistanut toimittajien laittamisen keskinäiseen paremmuusjärjestykseen toisiinsa nähden varsinaisia jatkotoimenpiteitä varten. Tarkoituksena on syventää yhteistyötä tärkeimpien toimittajien kanssa.

Concurrent : Easy to use Python computing environment

Concurrent aims to be a different type of task distribution system compared to what MPI like system do. It adds a simple but powerful application abstraction layer to distribute the logic of an entire application onto a swarm of clusters holding similarities with volunteer computing systems. Traditional task distributed systems will just perform simple tasks onto the distributed system and wait for results. Concurrent goes one step further by letting the tasks and the application decide what to do. The programming paradigm is then totally async without any waits for results and based on notifications once a computation has been performed.

Expressive writing intervention for mothers following the birth of their premature baby.

The birth of a preterm infant is in most cases unexpected and can be a distressing experience for parents. Parents of premature babies report more stress, experience more adjustment difficulties and need for support during the first year after delivery compared to parents of infants born at term. It has been documented that parents may experience posttraumatic stress reactions, anxiety and depression following the premature birth of their baby, which subsequently may impact on the mother-baby-interactions, their attachment relationship and the cognitive, social and behavioural development of the baby. In this pilot study, we offered an expressive writing intervention to women who recently had a premature baby to alleviate their psychological distress and to improve their physical health. During the expressive writing intervention, women were asked to write down their deepest thoughts and feelings about the most traumatic aspect of their experience of having a premature baby for 15 min over three consecutive days. The aims of the study were as follows: (1) To evaluate the effect of expressive writing on psychological and physical health in women who recently had a premature baby. (2) To evaluate the effect of expressive writing on the use of healthcare services and medication in this population. (3) To evaluate the acceptability and feasibility of this intervention for this population. Forty participants were randomly allocated to either the expressive writing intervention group or a wait list control group. Pre- and post questionnaires to evaluate the effectiveness of the expressive writing intervention, as well as their acceptability and feasibility were completed. The intervention took place when the baby was 3 months of corrected age. Post-measures were completed at 1 and 3 months following the intervention. Results and their clinical implications will be discussed with regards to the implementation of this safe and cost-effective method as a preventative measure in the routine care of women who recently gave birth to a premature baby

A cast of shadow on adjuvant radiotherapy for prostate cancer: A critical review based on a methodological perspective.

OBJECTIVE: To perform a critical review focusing on the applicability in clinical daily practice of data from three randomized controlled trials (RCTs): SWOG 8794, EORTC 22911, and ARO/AUO 96-02. METHODS AND MATERIALS: An analytical framework, based on the identified population, interventions, comparators, and outcomes (PICO) was used to refine the search of the evidence from the three large randomized trials regarding the use of radiation therapy after prostatectomy as adjuvant therapy (ART). RESULTS: With regard to the inclusion criteria: (1) POPULATION: in the time since they were designed, in two among three trial (SWOG 8794 and EORTC 22911) patients had a detectable PSA at the time of randomization, thus representing de facto a substantial proportion of patients who eventually received salvage RT (SRT) at non-normalised PSA levels rather than ART. (2) INTERVENTIONS: although all the trials showed the benefit of postoperative ART compared to a wait-and-see approach, the dose herein employed would be now considered inadequate; (3) COMPARATORS: the comparison arm in all the 3 RCTs was an uncontrolled observation arm, where patients who subsequently developed biochemical failure were treated in various ways, with up to half of them receiving SRT at PSA well above 1ng/mL, a level that would be now deemed inappropriate; (4) OUTCOMES: only in one trial (SWOG 8794) ART was found to significantly improve overall survival compared to observation, with a ten-year overall survival rate of 74% vs. 66%, although this might be partly the result of imbalanced risk factors due to competing event risk stratification. CONCLUSIONS: ART has a high level of evidence due to three RCTs with at least 10-year follow-up recording a benefit in biochemical PFS, but its penetrance in present daily clinics should be reconsidered. While the benefit of ART or SRT is eagerly expected from ongoing randomized trials, a dynamic risk-stratified approach should drive the decisions making process.