Organ-preserving Treatment of Localized Prostate Cancer: a Comparative Analysis of Current Strategies

Abstract

The objective: to compare oncological outcomes, functional consequences, and quality of life in organ-preserving treatment modalities for localized prostate cancer – external beam radiation therapy (EBRT), stereotactic RT (stereotactic body radiation therapy – SBRT), brachytherapy (BT), and focal therapy (FT) – with radical prostatectomy (RP). Materials and methods. An analytical review of the PubMed/MEDLINE, Scopus, Web of Science, and the Cochrane Library databases was conducted for the years 2015–2025, including randomized controlled trials (RCTs) (SPCG-4, PIVOT, ProtecT, CHHiP, PROFIT, RTOG 0415, ASCENDE-RT), systematic reviews, meta-analyses, and multicenter cohort studies (n ≥ 200). Results. In the PIVOT and ProtecT trials, RP did not demonstrate an advantage in overall survival compared with active surveillance and RT. Urinary incontinence and erectile dysfunction occurred in 10–20% and 40–70% of patients, respectively. Moderately hypofractionated RT was no less effective than standard (CHHiP: hazard ratio (HR) = 0.84; 90% confidence interval [0.68–1.03]). SBRT provided a 5-year biochemical recurrence-free survival (bRFS) rate of ≈ 95% with late toxicity of ≥ G3 < 2%. LDR-BT (low-dose-rate) achieved a 10-year bRFS rate of 90–95% in low-risk patients. A brachytherapeutic boost increased 9-year bRFS to 83% vs 62%, but increased late urological toxicity ≥ G3 (18.4% vs 5.2%). FT demonstrated a 5-year treatment-failure-free survival of 70–96% while maintaining urinary continence in > 95% of patients; however, there were no direct RCTs comparing it with radical treatments. Androgen-deprivation therapy combined with RT improved biochemical event-free survival (HR = 0.52), without a statistically significant advantage in overall survival. According to the EPIC-26 study, RP most significantly impaired urinary and sexual function, whereas RT and BT primarily affected the bowel and urinary domains. Conclusions. The choice of treatment should be based on the NCCN/EAU risk group, the expected functional profile, and the patient’s preferences. SBRT, BT, and FT may be alternatives to RP for appropriate risk groups.