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The optimal management strategy for men with newly diagnosed, clinically-
localized prostate cancer (PCa) remains in debate. PCa is second only to lung cancer in mortality burden among men in the United States.1

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However, the heterogeneous natural history of the 
disease, which may be indolent even without treatment,2 together with the not-insignificant risk of treatment-related side effects,3 complicates decision-making. A benefit to treatment (with surgery) has been demonstrated compared to patients managed with watchful waiting in a recent randomized trial.4 In this study, the relative risk of death from PCa among men assigned to radical prostatectomy (RRP) was 0.56.4

Assessing treatment options

The majority of U.S. men today do receive active treatment for PCa,5 in the form of either RRP, which may be performed via open, laparoscopic, and robotic-assisted approaches, or radiation therapy (RT), which includes both external beam radiation therapy (EBRT) and brachytherapy (BT).

Unfortunately, contemporary prospective randomized studies comparing the efficacy and side effects following these treatments are lacking. Two early trials compared these modalities and found a significant reduction in disease progression after RRP.6,7

Nevertheless, the studies have been criticized for relatively small patient numbers (n=97 and 95, respectively) as well as details regarding methodology and reporting.8 A more recent effort to evaluate treatment outcomes in the clinical trial setting was the Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial (SPIRIT), which randomized men to RRP or BT.

However, the trial accrued only 56 patients at 31 centers over two years, and was closed early.9 Meanwhile, the Prostate Testing for Cancer and Treatment (ProtecT) study, which includes arms for RRP, EBRT, and watchful waiting, is ongoing and so it will be years before mature data are available for reporting.10

Given the lack of contemporary, large-scale randomized trial data comparing the efficacy of different active therapeutic options for PCa, treatment of these patients continues to be largely based upon individual physician experience and biases. Indeed, an analysis of the Cancer of the Prostate Strategic Urologic Research Endeavor (CaPSURE) dataset, a primarily community-based cohort, found that treatment for localized PCa varied considerably with patient age, comorbidity, and socioeconomic status.5

Moreover, substantial variation in management practices existed across clinical sites that was not explained by case-mix or patient factors.5 Thus, it is not surprising that guidelines from both the American Urological Association11 and the National Comprehensive Cancer Network (NCCN)12 for the management of clinically-localized PCa include both surgery and radiation therapy as alternatives, without providing conclusions regarding relative efficacy. 

Here, then, the purpose is to present for review data from several of the most recent retrospective comparative series that have evaluated outcomes following surgery and radiation, at tertiary referral centers and in larger, population-based datasets, in order to provide an updated assessment of the relative oncologic efficacy and toxicity profiles associated with RRP and RT.