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Comparative effectiveness of radical prostatectomy and radiotherapy in prostate cancer: observational study of mortality outcomes

BMJ 2014; 348 doi: (Published 27 February 2014) Cite this as: BMJ 2014;348:g1502
  1. Prasanna Sooriakumaran, assistant professor and senior clinical researcher12,
  2. Tommy Nyberg, statistician3,
  3. Olof Akre, associate professor4,
  4. Leif Haendler, consultant1,
  5. Inge Heus, statistician5,
  6. Mats Olsson, consultant1,
  7. Stefan Carlsson, consultant1,
  8. Monique J Roobol, associate professor5,
  9. Gunnar Steineck, professor36,
  10. Peter Wiklund, professor1
  1. 1Department of Urology, Karolinska University Hospital, Stockholm, Sweden
  2. 2Surgical Intervention Trials Unit, Nuffield Department of Surgical Sciences, University of Oxford, Oxford, UK
  3. 3Clinical Cancer Epidemiology, Department of Oncology-Pathology, Karolinska Institutet, Stockholm, Sweden
  4. 4Clinical Epidemiology Unit, Department of Medicine (Solna), Karolinska Institutet, Stockholm, Sweden
  5. 5Department of Epidemiology, Erasmus University Medical Center, Rotterdam, Netherlands
  6. 6Division of Clinical Cancer Epidemiology, Department of Oncology, Institute of Clinical Sciences, Sahlgrenska Academy at the University of Gothenburg, Sweden
  1. Correspondence to: P Wiklund peter.wiklund{at}
  • Accepted 5 February 2014


Objective To compare the survival outcomes of patients treated with surgery or radiotherapy for prostate cancer.

Design Observational study.

Setting Sweden, 1996-2010.

Participants 34 515 men primarily treated for prostate cancer with surgery (n=21 533) or radiotherapy (n=12 982). Patients were categorised by risk group (low, intermediate, high, and metastatic), age, and Charlson comorbidity score.

Main outcome measures Cumulative incidence of mortality from prostate cancer and other causes. Competing risks regression hazard ratios for radiotherapy versus surgery were computed without adjustment and after propensity score and traditional (multivariable) adjustments, as well as after propensity score matching. Several sensitivity analyses were performed.

Results Prostate cancer mortality became a larger proportion of overall mortality as risk group increased for both the surgery and the radiotherapy cohorts. Among patients with non-metastatic prostate cancer the adjusted subdistribution hazard ratio for prostate cancer mortality favoured surgery (1.76, 95% confidence interval 1.49 to 2.08, for radiotherapy v prostatectomy), whereas there was no discernible difference in treatment effect among men with metastatic disease. Subgroup analyses indicated more clear benefits of surgery among younger and fitter men with intermediate and high risk disease. Sensitivity analyses confirmed the main findings.

Conclusions This large observational study with follow-up to 15 years suggests that for most men with non-metastatic prostate cancer, surgery leads to better survival than does radiotherapy. Younger men and those with less comorbidity who have intermediate or high risk localised prostate cancer might have a greater benefit from surgery.


  • This project was made possible by the continuous work of the National Prostate Cancer Registry of Sweden steering group: Pär Stattin (chairman), Anders Widmark, Camilla Thellenberg, Ove Andrén, Anna Bill-Axelsson, Ann-Sofi Fransson, Magnus Törnblom, Stefan Carlsson, Marie Hjälm-Eriksson, Bodil Westman, Bill Pettersson, David Robinson, Mats Andén, Jan-Erik Damber, Jonas Hugosson, Maria Nyberg, Göran Ahlgren, Ola Bratt, René Blom, Lars Egevad, Calle Walller, Olof Akre, Per Fransson, Eva Johansson, Fredrik Sandin, Hans Garmo, Mats Lambe, Karin Hellström, Annette Wigertz, and Erik Holmberg. PS is part funded by the National Institute for Health Research Oxford Biomedical Research Centre based at Oxford University Hospitals NHS Trust and the University of Oxford. The views expressed are those of the author and not necessarily those of the NHS, the National Institute for Health Research, or the Department of Health. PS was also a European urology scholarship fund fellow during part of the time this research was performed. OA is supported by a grant from the Swedish Cancer Society. PW is supported by a grant from the Swedish Research Council (K2013-99X-22283-01-3).

  • Contributors: PS was involved at every stage from the literature search, planning and design of the study, data abstraction, data analysis, data interpretation, and writing. TN was involved with data abstraction and data analysis. OA was involved with data interpretation and writing. LH was involved with the study plan and design and data abstraction. IH was involved with data abstraction and data analysis. MO was involved with study plan and design. SC was involved with the study plan and design. MR supervised data abstraction and data analysis, and was involved with data interpretation. GS was involved with data interpretation and editing the manuscript for important intellectual content. PW was involved at every stage but especially with data interpretation and editing the manuscript for important intellectual content. He is guarantor. All authors had full access to the data (including statistical reports and tables) in the study and can take responsibility for the integrity of the data and the accuracy of the data analysis.

  • Funding: This study received no funding. The PCBaSe database, however, is funded by the Swedish Research Council (25-2012-5047).

  • Competing interests: All authors have completed the ICMJE uniform disclosure form at (available on request from the corresponding author) and declare that: none of the authors have support for the submitted work; none of the authors have relationships with any companies that might have an interest in the submitted work in the previous three years; none of the authors’ spouses, partners, or children have any financial relationships that may be relevant to the submitted work; and none of the authors have non-financial interests that may be relevant to the submitted work.

  • Ethical approval: This study was approved by the central research ethics committee and the regional ethical review board in Stockholm.

  • Data sharing: No additional data available.

  • Transparency: The senior author (PW) affirms that the manuscript is an honest, accurate, and transparent account of the study being reported; no important aspects of the study have been omitted; and there were no discrepancies from the study as planned.

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