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.
All-cause mortality was about 21-22% in every arm: men in the trial were far more likely to die of something other than prostate cancer.
Radical treatment did halve metastasis (9.4% with monitoring versus 4.7% surgery and 5.0% radiotherapy) without changing survival over 15 years.
Urinary leakage was worst after surgery: at 12 years about 24% used a pad daily, versus roughly 3-8% after radiotherapy.
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The full explanation.
The finding that anchors this decision
The ProtecT trial studied men in the UK with PSA-detected localised 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 almost identical across the arms at around 21-22%. In other words, these men were roughly ten 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. At 12 years, around 24% of men who had surgery were using at least one absorbent pad a day. After radiotherapy the figure was roughly 3-8%, and on monitoring it was 9-11%.
Bowel function was worst after radiotherapy. About 12% reported faecal leakage at least weekly at 12 years, versus about 6% in the other two groups.
Sexual function dropped sharply and at once after surgery. At seven years, 18% of men who had surgery reported erections firm enough for intercourse. That compares with about 27% after radiotherapy and 30% on monitoring. By 12 years the groups had converged to roughly 13-17%, as age and other conditions caught up with everyone.
The shapes of the curves differ too. Surgery front-loads its harms. They are worst at first, then partly recover. Radiotherapy's effects tend to build slowly over months to years.
What each treatment involves
Radical prostatectomy removes the prostate, usually with robot assistance. It is one operation under general anaesthetic. You keep a catheter for one to two weeks, then recover over several weeks. It produces a pathology report on the whole gland. And if the PSA rises later, radiotherapy is still available as salvage treatment, meaning treatment given when the first treatment has not worked.
Radiotherapy comes in two forms. External beam runs over several weeks, and is increasingly given as fewer, larger sessions. Brachytherapy places radioactive sources into the prostate. Neither is an operation, and neither needs a hospital stay. But the course runs over a longer period. For intermediate and higher risk disease it is often paired with several months of hormone therapy. That brings its own hot flushes, fatigue, loss of libido and bone density effects. Salvage surgery after radiotherapy is technically harder and much less commonly done.
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. Most had low- and intermediate-risk PSA-detected disease. They joined before MRI-targeted biopsy, and before some current radiotherapy and surgical techniques. So the trial tells you much less about high-risk or locally advanced disease. It 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?
Seeing both a urologist and a radiation oncologist before you decide is standard and sensible. Each will naturally describe their own treatment best. Ask both the same questions and compare the answers.
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Common questions
If survival is the same, why treat at all?
Radical treatment roughly halved the chance of the cancer spreading, and avoiding metastatic disease matters even when 15-year mortality is unchanged. It is also why active surveillance is offered rather than mandated — the trade-off between avoiding spread and accepting side effects is a personal one.
Does ProtecT apply to my cancer?
It enrolled men between 1999 and 2009 with PSA-detected localised disease, mostly low and intermediate risk, before MRI-targeted biopsy and some current radiotherapy and surgical techniques. It says much less about high-risk or locally advanced disease. Ask your team where your risk category sits relative to that population.
Can I have radiotherapy later if surgery does not cure it?
Yes — salvage radiotherapy after surgery is well established. The reverse is harder: surgery after radiotherapy is technically more difficult and less commonly done. That asymmetry is one of the practical considerations people weigh.
Does radiotherapy always mean hormone therapy too?
Not always, but for intermediate and higher risk disease radiotherapy is often combined with several months of hormone therapy, which brings hot flushes, fatigue, loss of libido and effects on bone density. If hormone therapy is proposed, ask how long for and what the side effects mean day to day.
Which side effects recover?
Surgery front-loads its harms — they are worst immediately and then partially recover over the first year. Radiotherapy effects tend to emerge more gradually over months to years. Asking about the shape of the curve, not just the final percentage, tends to be more useful.
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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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How this page was created
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. We do not employ clinicians and do not intend to — our work 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 checked line by line against the sources listed on it. That confirms the sources support what the page says. 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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