Radiotherapy versus Prostatectomy: a Question of Survival or Survivorship? Addressing Ongoing Questions and Controversies in the Management of Localised Prostate Cancer in the UK

The landscape of prostate cancer is evolving. Although the introduction of prostate-specific antigen (PSA) testing into clinical practice some 30 years ago has seen a greater detection of organ-confined disease due to stage migration, as yet this has not resulted in any significant reduction in mortality [1]. In addition, although a third of cases are diagnosed in men above the age of 75 years, only a minority actually undergo curative treatment, leaving a significant proportion of men having to live with their prostate cancer. With an increasing demand for preserving quality of life and functional outcome, there is thus an impetus to define organ-confined disease more clearly and select patients for treatment who are at risk of metastatic spread while avoiding over-treating those with indolent cancer. The management of localised prostate cancer continues to polarise opinion between surgery and radiotherapy. This is largely because there has never been a prospective randomised trial directly comparing them to inform decision making. Attempts at retrospective comparisons/metaanalysis have yielded conflicting results, mainly due to inherent bias when comparing two fundamentally different approaches to treatment [2]. These include a failure to include androgen deprivation therapy with radiotherapy, using surrogate end points rather than overall and cancerspecific survival, and the obvious discrepancy between definitive pathology obtained at prostatectomy versus the limited histology that guides radiotherapy treatment. In addition, many retrospective studies were started in the pre-PSA era. These issues are discussed in more detail in the accompanying editorial by Dr Roach [3], but it would seem that any survival gains between either modality are small and not clinically meaningful. Thus, the more important factors driving the treatment decision are probably related to the morbidity of treatment and the impact on quality of life for the individual.