Surgery or Radiotherapy for Prostate Cancer: Is the Debate Ending?
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📌 Surgery or Radiotherapy in High-Risk Prostate Cancer?
The best approach to high-risk prostate cancer is among the questions I encounter most often as an oncologist and still consider most deeply. Uncertainty complicates decisions for physicians and patients alike. My approach is to explain confusing issues clearly through scientific evidence. Today's study adds a new dimension to this debate.
European Urology Oncology published a study on July 19, 2025 , examining current guidelines that present radical prostatectomy (surgery) and radiotherapy + androgen deprivation therapy (ADT) as equivalent options despite limited strong evidence favoring either. Researchers combined patient data from two large phase 3 randomized trials (NRG/RTOG 0521 and CALGB 90203) in a pooled analysis .
Among the strongest evidence available, the results suggest that, in high-risk prostate cancer, radiotherapy-based approaches may offer better disease control than surgery .
Why Does Radiotherapy Stand Out in Reducing Distant Metastases?
The analysis evaluated data from 1290 patients . Some received radiotherapy with long-term ADT, while others underwent radical prostatectomy followed by personalized adjuvant treatment.
- 32% reduction in distant metastasis risk: At 8 years, distant metastases occurred in 15%of the radiotherapy + ADT group versus 22% of the surgery group.
- Lower biochemical recurrence: 32% with radiotherapy versus 68% with surgery—nearly a twofold difference.
These findings suggest radiotherapy may substantially improve disease control. However, the debate does not end here.
⚖️ Why Is the Debate Not Over?
Despite clear differences in metastasis and recurrence, death risk after distant metastasis did not differ between groups. Long-term survival was therefore similar. More data are still needed to determine the best treatment definitively.
👥 Individualization and a Multidisciplinary Approach
Oncology decisions are not based on statistics alone. Choosing treatment requires assessment of the whole patient. I therefore particularly recommend that all my high-risk patients see both a urologic oncologist and a radiation oncologist .
- Age and health: Surgery may be too burdensome for a 75-year-old with an aggressive tumor, but still the first choice for a healthy 65-year-old.
- Treatment experience: Urinary incontinence and sexual dysfunction can be more frequent after surgery than radiotherapy. This is critical for many patients' decisions.
🔮 What Comes Next?
Although this analysis strongly favors radiotherapy, surgery remains important. Future randomized trials directly comparing surgery and radiotherapy, including the ongoing SPCG-15 , will clarify the answer. Until then, our job is to offer patients an honest, transparent, individualized roadmap.
Final Thoughts: The right oncology decision comes from multidisciplinary assessment of age, tumor biology, other illnesses, and life expectations as well as statistics. Fighting cancer is a marathon rather than a sprint, and every step requires careful planning.
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