Prostate Cancer Treatment Options: Surgery, Radiation, and Active Surveillance

One in Eight American Men Will Receive This Diagnosis

Prostate cancer is the most common non-skin cancer in American men and the second leading cause of cancer death in men in the United States, with approximately 288,000 new cases diagnosed annually. Yet the five-year survival rate for localized and regional prostate cancer is 99.9%, reflecting both the slow natural history of many prostate tumors and the effectiveness of available treatments. The central challenge in prostate cancer management is not always "how do we treat this?" — it is often "should we treat this, and when?"

Risk stratification, driven by Gleason score (now rendered as Grade Group 1 through 5), PSA level, and clinical staging, determines which men benefit from immediate intervention versus those who can safely be monitored.

Risk Stratification: The Foundation of Treatment Planning

The American Urological Association (AUA) and American Society for Radiation Oncology (ASTRO) jointly use a risk group system that drives treatment decisions.

Genomic testing panels — Oncotype DX Genomic Prostate Score, Decipher, and Prolaris — refine these categories by examining tumor gene expression, helping distinguish indolent Grade Group 1 cancers from those with molecular features suggesting aggressive behavior.

Active Surveillance: Watching Without Treating

Watchful waiting is not passive neglect. Active surveillance (AS) is a structured monitoring protocol for low- and very low-risk prostate cancer that defers definitive treatment unless disease progression occurs. The landmark ProtecT trial, published in the New England Journal of Medicine in 2016, followed 1,643 men with localized prostate cancer for 10 years and found no statistically significant difference in prostate cancer-specific mortality between active monitoring, surgery, and radiation — all groups showed approximately 1% disease-specific mortality at 10 years.

Active surveillance protocol typically includes:

• PSA testing every 3–6 months for the first 2 years, then every 6–12 months thereafter
• Repeat prostate biopsy at 1–2 years after diagnosis, then every 2–5 years
• Multiparametric MRI (mpMRI) of the prostate to guide targeted biopsy and monitor lesion size
• Definitive treatment triggered by grade reclassification to Grade Group 2 or higher, or patient preference

Approximately 50–60% of men on AS for Grade Group 1 disease remain on surveillance at 10 years without progression requiring treatment, according to data from the University of Toronto cohort.

Radical Prostatectomy

Surgery cures many men. Radical prostatectomy involves complete removal of the prostate gland, seminal vesicles, and sometimes pelvic lymph nodes. Robot-assisted radical prostatectomy (RARP) using the da Vinci surgical system has become the dominant approach in the United States, accounting for over 85% of prostatectomies. Compared to open surgery, RARP is associated with reduced blood loss, shorter hospital stay (typically 1–2 days), and equivalent oncologic outcomes.

Key surgical considerations include:

• Nerve-sparing technique: bilateral nerve-sparing preserves erections in approximately 70–80% of younger men with favorable anatomy, though recovery may take 12–24 months
• Urinary continence recovery: approximately 90% of men recover continence within 12 months, though rates vary by age and surgical technique
• Biochemical recurrence (PSA rise above 0.2 ng/mL after surgery) occurs in approximately 15–40% of patients at 10 years depending on pathologic stage
• Lymph node dissection at the time of prostatectomy provides staging information and may have therapeutic benefit for high-risk disease

Radiation Therapy Approaches

Radiation and surgery produce equivalent cure rates for localized disease. Three main modalities exist:

External beam radiation therapy (EBRT) delivers precisely targeted radiation over 5–9 weeks. Modern EBRT techniques include intensity-modulated radiation therapy (IMRT) and volumetric arc therapy (VMAT), which conform the radiation dose tightly to the prostate while sparing the rectum and bladder. Stereotactic body radiotherapy (SBRT) — also called stereotactic ablative radiotherapy — delivers the equivalent dose in just 5 fractions over 1–2 weeks; the PACE-B trial confirmed non-inferiority to conventional fractionation for low- and intermediate-risk disease.

Brachytherapy implants radioactive seeds (low-dose rate, LDR) or temporary high-dose rate (HDR) catheters directly into the prostate. LDR brachytherapy using iodine-125 or palladium-103 seeds is a single outpatient procedure for low-risk disease with excellent 10-year cancer control rates of 90–95%.

Combination therapy for high-risk disease typically pairs EBRT with androgen deprivation therapy (ADT) for 18–36 months, a combination shown to improve overall survival by multiple randomized trials including RTOG 85-31 and EORTC 22863.

Hormone Therapy and Systemic Treatment

Prostate cancer is driven by testosterone. Androgen deprivation therapy (ADT), achieved via luteinizing hormone-releasing hormone (LHRH) agonists (leuprolide, goserelin) or antagonists (degarelix, relugolix), reduces testosterone to castrate levels (<50 ng/dL) and is foundational in locally advanced and metastatic disease.

Approximately 10–15% of metastatic prostate cancers harbor BRCA1, BRCA2, or other homologous recombination repair gene mutations, making them eligible for PARP inhibitor therapy. Germline genetic testing is now recommended for all men with metastatic prostate cancer.

This article is for informational purposes only. Consult a qualified healthcare professional before making medical decisions.