The short answer
At 15 years the ProtecT trial found no significant difference in prostate cancer deaths between surgery, radiotherapy and active monitoring. Side-effect profiles differ, and that drives the choice.
In ProtecT, 2.7% of men died of prostate cancer by 15 years — 3.1% with active monitoring, 2.2% after surgery, 2.9% after radiotherapy — with no significant difference between groups.
Death from any cause was 21.7% overall, with similar numbers in all three groups. Men in the trial were far more likely to die of something other than prostate cancer.
Radical treatment roughly halved metastasis (9.4% with monitoring versus 4.7% surgery and 5.0% radiotherapy) without changing survival over 15 years.
Urinary leakage needing pads was most common after surgery: 18-24% over years 7 to 12, versus 3-8% after radiotherapy and 9-11% on monitoring.
On this page
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The whole article, with every detail and caution.
This page is for men with localized prostate cancer who are choosing between surgery and radiation. It explains what a large trial found and how the side effects differ.
The finding that anchors this decision
The ProtecT trial studied men in the UK with PSA-detected localized prostate cancer. It randomly assigned them to surgery, radiotherapy, or active monitoring. It then followed them for a median of 15 years. The central result: death from prostate cancer was uncommon, and the three groups did not differ significantly.
At 15 years, 2.7% of the men had died of prostate cancer. That was 3.1% in the active monitoring group, 2.2% after surgery, and 2.9% after radiotherapy. None of those gaps was statistically significant. Death from any cause was 21.7% overall, with similar numbers in all three groups. In other words, these men were about eight times more likely to die of something other than their prostate cancer.
Treatment did change one outcome. The cancer spread in 9.4% of the monitoring group. That compares with 4.7% after surgery and 5.0% after radiotherapy. Radical treatment roughly halved the chance of metastasis, meaning spread to distant parts of the body. But it did not change survival over 15 years.
The point is not that treatment does not matter. It is that for this kind of cancer, choosing between surgery and radiotherapy is not a choice about how long you will live. It is a choice about what you will live with.
What differs: the side-effect profiles
ProtecT also collected patient-reported outcomes for 12 years. That is where the real difference sits.
Urinary leakage was worst after surgery. Across years 7 to 12, 18-24% of men who had surgery had urinary leakage needing pads. After radiotherapy the figure was 3-8%, and on monitoring it was 9-11%.
Bowel function was worst after radiotherapy. About 12% reported leakage of stool (fecal leakage) at 12 years, versus about 6% in the other two groups.
Sexual function was lowest after surgery at first. At seven years, 18% of men who had surgery reported erections sufficient for intercourse. That compares with about 27% after radiotherapy and 30% on monitoring. By 12 years all groups had converged to low levels.
Men on active monitoring saw gradual age-related declines in sexual and urinary function.
What each treatment involves
Radical prostatectomy removes the prostate, usually with robot assistance. It is one operation. The ACS says the catheter usually stays in for about 1 to 2 weeks, you may stay a few days in hospital, and activities are limited for about 4 to 6 weeks. If the PSA rises later, radiation may be an option.
Radiotherapy comes in two forms. External beam is sometimes given as fewer, larger sessions. Brachytherapy places radioactive seeds into the prostate. External beam is given as outpatient visits, usually 5 days a week for at least several weeks, though some plans take only a few days. Brachytherapy is placed in an operating room, and some people stay overnight. The ACS lists bowel irritation, urinary symptoms, gradually developing erection problems and fatigue as side effects. Hormone therapy can add hot flashes, impaired sexual function, loss of desire and weakened bones (NCI).
Active surveillance is still a real third option for lower-risk disease. It was the comparator that made the trial's headline result meaningful.
What ProtecT does not settle
The men enrolled between 1999 and 2009 with PSA-detected disease. More than one third had intermediate- or high-risk disease. They joined before MRI-targeted biopsy, and before some current radiotherapy and surgical techniques. So ask your team how your own risk category compares. The trial also does not compare today's exact protocols head to head.
How people actually decide
Once survival stops being the tiebreaker, other things settle it. Which side effect would you find hardest to live with? How do you feel about an operation, versus weeks of appointments? Would hormone therapy be part of the radiotherapy plan? How are your continence and sexual function now? And which salvage options does each path leave open?
Talking with both a urologist and a radiation oncologist before you decide is a reasonable step. Ask both the same questions and compare the answers.
Sources
- Hamdy FC et al. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med 2023 (PubMed/Europe PMC abstract)
- Donovan JL et al. Patient-reported outcomes 12 years after localized prostate cancer treatment. NEJM Evid 2023 (PubMed/Europe PMC abstract)
- NCI PDQ: Prostate Cancer Treatment (patient version)
- ACS: Surgery for Prostate Cancer
- ACS: Radiation Therapy for Prostate Cancer
- NCI: Prostate-Specific Antigen (PSA) Test
Common questions
If survival is the same, why treat at all?
In ProtecT, spread of the cancer (metastasis) was about half as common after surgery or radiotherapy as on monitoring, even though 15-year prostate cancer deaths did not differ significantly. Weighing less spread against side effects is a personal choice.
Does ProtecT apply to my cancer?
It enrolled men between 1999 and 2009 with PSA-detected localised disease. More than one third had intermediate- or high-risk disease. It began before MRI-targeted biopsy and some current techniques, so it may not match today's care exactly. Ask your team where your risk category sits relative to that population.
Can I have radiotherapy later if surgery does not cure it?
Sometimes. If the PSA rises after surgery, radiation may be an option. Ask your team which later treatments would still be open to you after each first choice.
Does radiotherapy always mean hormone therapy too?
Not always. In ProtecT, the radiotherapy group also had hormone therapy first. The NCI lists hot flashes, impaired sexual function, loss of desire for sex and weakened bones as hormone therapy side effects. If it is proposed, ask how long it would last.
Which side effects recover?
The NCI notes that impotence and urinary problems after radiation may get worse with age. In ProtecT, men on monitoring also saw gradual age-related declines. Ask your team how each side effect is likely to change over time.
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Written by: Cancer ExplainedSources last checked: 2026-07-30 what this meansLast updated: 2026-08-10Next planned review: 2027-01-30
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Cancer Explained does not originate medical claims. Every page restates guidance already published by the National Cancer Institute, the CDC, the USPSTF and the FDA, in plain language, with the source cited so you can check the original yourself. AI does the translating and organizing; automated checks test claims, citations, clarity and safety before anything publishes, and this is translation and navigation, not clinical judgment. Nothing here is personal medical advice, and no page can account for your particular situation.
Editorial status: Source checked — This page was written with AI assistance and then compared with the sources listed on it, looking for statements those sources do not back up. That check is not a sentence-by-sentence record and can miss errors. It is not a medical review, and it does not confirm the page is complete or right for your situation.
Human medical review: not completed. Pages here are not signed off by a clinician before they publish. That is not an oversight we are quietly working around: we restate published guidance and cite it, so the authority belongs to the source rather than to us, and every page names where its claims come from — you can verify us instead of trusting us. Where a volunteer clinician has reviewed a page, their name and credentials appear on it; where no name appears, no clinician has checked it. We are glad to have reviewers and are recruiting them, and we do not hold pages back waiting for one. Use this site to understand your situation and to ask better questions of the people treating you.
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