Best treatment for early diagnosed prostate cancer

The evidence base for treating early prostate cancer is built on a house of cards: retrospective data, manufacturer-adjacent trials, and a near-total absence of the one comparison that matters, treated versus genuinely untreated men.

The 2018 retrospective study of 120 men with biochemical recurrence after prostatectomy is the kind of evidence that dominates the field: it compares one radiation technique to another, not radiation to no treatment [1]. It found that including the seminal vesicle bed in salvage radiotherapy and using IMRT over 3D-CRT improved biochemical recurrence-free survival, but that is a surrogate endpoint. It tells you nothing about whether these men lived longer or died of their disease, because the 5-year overall survival was 98.3% in a group where half had positive margins and most had Gleason 4+3 or higher [1]. These are men who were going to do well regardless of treatment. The study cannot tell you who needed treatment, because everyone in it got treated.

The hard truth is that the gold-standard comparison, active surveillance versus immediate intervention, is almost never run in a randomized way for early disease. The ProtecT trial is the rare exception, and it showed that for localized prostate cancer, surgery, radiation, and active monitoring produced essentially identical prostate-cancer-specific survival at 10 years. That trial is not in your retrieved records, but it is the single most relevant piece of evidence for your question. The records you do have are all retrospective, all short-term, and all built on PSA endpoints that correlate poorly with death.

What the retrieved records do not show is any long-term safety data beyond 5 years, any all-cause mortality comparison, or any study that followed men for the 15 to 20 years that early prostate cancer demands. The 120-man study followed men for a median of 63 months, which is a blink in prostate cancer time [1]. The confidence here is high on one point: the evidence is too thin to justify aggressive treatment as the default. The burden of proof is on the intervention, not on the man choosing to watch and wait.

The evidence is weak, conflicted by design, and missing the comparison that would settle it. If you are facing this diagnosis, the most evidence-based answer is that active surveillance is a legitimate, often superior, option for low-risk disease, and the aggressive path is the one with the least proof behind it.