Reviewed for medical accuracy by Dr Evelyne Jonniaux, Medical Advisor
Last updated 17 September 2026
Localised prostate cancer: 96.6% survival at 15 years, with no immediate treatment
The British ProtecT trial (NEJM, 2023) allocated 1,643 men between active monitoring, prostatectomy and radiotherapy, and followed them for fifteen years. Prostate cancer mortality is 3.1% under monitoring, 2.2% after surgery and 2.9% after radiotherapy, with no significant difference between the three. Of the 356 deaths recorded, 164 were from another cancer. Metastases, on the other hand, are twice as frequent under monitoring: 9.4% against 4.7%. These figures describe populations, not one man, and the choice of treatment is an individual medical decision. Noria Health arranges a full urological work-up near Brussels within 24 to 48 hours.
What ProtecT measured at fifteen years
82,429 men aged 50 to 69 were PSA tested, 2,664 received a diagnosis of localised cancer, and 1,643 accepted randomisation. Median follow-up is fifteen years, with complete data for 98% of them.
| At 15 years | Monitoring | Prostatectomy | Radiotherapy |
|---|---|---|---|
| Prostate cancer deaths | 17 (3.1%) | 12 (2.2%) | 16 (2.9%) |
| Hazard ratio against monitoring | reference | 0.66 (0.31 to 1.39) | 0.88 (0.44 to 1.74) |
| All-cause deaths | 124 | 117 | 115 |
| Metastases | 51 (9.4%) | 26 (4.7%) | 27 (5.0%) |
| Clinical progression | 141 (25.9%) | 58 (10.5%) | 60 (11.0%) |
| Long-term hormone therapy | 69 (12.7%) | 40 (7.2%) | 42 (7.7%) |
The p value for the three-arm primary comparison is 0.53. Cancer-specific survival at fifteen years is 96.6% under monitoring, 97.2% after surgery and 97.7% after radiotherapy.
Two readings hold at once. On mortality, the three strategies are equivalent. On metastases and progression, immediate treatment halves the risk. A man deciding should know both sentences are true together.
One figure is often left out: in the monitoring arm, 61.1% of men had eventually received radical treatment by fifteen years. Active monitoring is not the absence of treatment, it is deferred treatment for the majority. And 133 men, 24.4%, were alive at the end of follow-up with no radical treatment and no hormone therapy.
The price of treatment, in numbers
These are the seven to twelve year data from ProtecT (NEJM Evidence, 2023), by intention to treat.
| What is measured | Prostatectomy | Monitoring | Radiotherapy |
|---|---|---|---|
| Urinary leakage needing pads, years 7 to 12 | 18% to 24% | 9% to 11% | 3% to 8% |
| Erections firm enough for intercourse, at 7 years | 18% | 30% | 27% |
| Nocturia, two or more voids a night, at 12 years | 34% | 47% | 48% |
| Faecal leakage, at 12 years | 6% | 6% | 12% |
At six months, in the as-treated analysis (Eur Urol, 2020), sexual dysfunction affects 95% of those operated on and 88% of those irradiated, and urinary incontinence 55% of those operated on. Six years later, erectile dysfunction persists in 85% of the surgical group and leakage needing a daily pad in 20% (BJU Int, 2022).
One counter-intuitive point deserves saying: general quality of life, anxiety and depression do not differ between the three groups, in any of the publications.
Three major trials, three answers, and why
ProtecT, PIVOT and SPCG-4 are often cited as if they answered the same question. They do not, and the gap between their populations explains the gap between their conclusions.
| Trial | Population | Comparator | Mortality result |
|---|---|---|---|
| ProtecT, 1,643 men, 15 years | 76% stage T1c, median PSA 4.6 | active monitoring with deferred curative treatment | no difference, p = 0.53 |
| PIVOT, 731 men, 22 years | about 50% T1c, median PSA 7.8 | observation | hazard ratio 0.84 (0.70 to 1.00), p = 0.044 |
| SPCG-4, 695 men, 29 years | only 12% T1c, mean PSA 13 | palliative watchful waiting | relative risk 0.55 (0.41 to 0.74), p below 0.001 |
SPCG-4 is the only one showing a clear mortality benefit, and its authors explain why themselves: the trial enrolled men diagnosed before the PSA screening era. Twelve per cent non-palpable tumours against seventy-six in ProtecT, and a mean PSA three times higher. It is not the same disease at the same moment.
PIVOT provides the most useful nuance in practice. In the nineteen-year follow-up (NEJM, 2017), the absolute reduction in all-cause mortality is 14.5 points in men at intermediate risk, with an interval from 2.8 to 25.6, and only 0.7 points in men at low risk, with an interval crossing zero. Across the whole cohort the mean survival gain is about one year.
The Cochrane review (2020) sums the position up in one sentence: the results favouring surgery rest largely on men diagnosed before widespread PSA screening, which limits how far they generalise.
The trap of five-year survival
The figure exists, it is official, and it is almost always misrepresented. For localised prostate cancer, the net five-year survival published by the American SEER registry is 100%. The one published by the NHS for stage 1 is 102.3%, with an interval from 101.6 to 102.9.
A percentage above 100 cannot be a proportion of survivors. The NHS explanation is that fewer men die than would be expected in the general population of the same age: screened men are healthier and better followed. That is a selection bias, not a therapeutic achievement. In the same file, observed survival at stage 1 is 89.0%.
Three further reasons make the figure useless for deciding. Lead time at diagnosis averages 5.4 to 6.9 years (Draisma, JNCI, 2009), enough on its own to carry men past the five-year mark without any treatment having changed anything. Overdiagnosis is estimated at 23% to 42% of screen-detected cancers. And above all, cancer-specific survival at fifteen years in the untreated arm of ProtecT is 96.6%. A high survival figure does not demonstrate that a treatment works.
What screening delivers, in absolute terms
The European ERSPC trial published its twenty-three year results (NEJM, 2025), across 162,236 men aged 55 to 69.
| What is measured | The figure |
|---|---|
| Relative reduction in prostate cancer mortality | 13%, rate ratio 0.87 (0.80 to 0.95) |
| Absolute risk reduction | 0.22% (0.10 to 0.34) |
| Excess incidence in the screened arm | 30%, rate ratio 1.30 (1.26 to 1.33) |
| Number needed to invite to avoid one death | 456 (306 to 943) |
| Number needed to diagnose to avoid one death | 12 (8 to 26) |
The benefit-harm balance improves with follow-up: at sixteen years it took 628 invitations and 18 diagnoses, at twenty-three years 456 and 12. Overdiagnosis is not a property of screening but of the patient: an individualised model (Gulati, JNCI, 2014) puts the risk of overdiagnosis between 2.9% and 88.1% depending on age, grade and PSA.
Active surveillance, cohort by cohort
| Cohort | Number | Treated by 10 years | Cancer-specific survival |
|---|---|---|---|
| Toronto, JCO, 2015 | 993 | 36.5% | 98.1% at 10 years, 94.3% at 15 |
| Johns Hopkins, JCO, 2015 | 1,298 | 50% | 99.9% at 10 and 15 years |
| GAP3 registry, Eur Urol Oncol, 2025 | 14,623 | 20% at low risk, 31% at intermediate | metastasis-free survival 99.4% at 10 years |
| ProtecT, monitoring arm | 545 | 54.8% | 96.6% at 15 years |
These rates are not comparable with each other: triggers for treatment, definitions of treatment and recruitment periods all differ. The spread from 20% to 54.8% at ten years makes the point. What is constant is cancer-specific mortality, between 0.1% and 1.5% across cohorts. In the Toronto cohort the ratio of non-prostate to prostate mortality is 9.2 to 1.
What the studies do not allow us to claim
ProtecT was conducted before multiparametric MRI, using a ten-core transrectal biopsy. Its monitoring protocol, a PSA every six to twelve months, is less intensive than current protocols which include MRI and confirmatory biopsy. The authors list this as a limitation, along with the fact that 98% of participants were of white origin.
PIVOT was underpowered: the original target was 2,000 men, 731 were recruited, and the authors say so in the paper.
Finally, the claim that one man in eight will develop prostate cancer is extremely widespread and we have not verified it in a primary source. We do not repeat it.
In practice, if this concerns you
Three questions structure the discussion. Which risk group are you in, since that is the only factor for which PIVOT shows a clear gap. Was a multiparametric MRI done before the biopsy, since the reference trials did not have one. And what is your life expectancy apart from the cancer, since in ProtecT half the deaths were from another cancer.
Noria Health arranges a full urological work-up near Brussels within 24 to 48 hours: PSA with its kinetics, clinical examination, multiparametric MRI of the prostate, and targeted biopsy where the imaging justifies it. The report is issued within 24 hours, follow-up is structured at D14, D30 and D90, and surgery is considered only around day 10 if it is needed.
What Noria Health does not do: recommend one strategy over another at a distance. The three options in ProtecT give the same mortality at fifteen years and very different side effects; it is your priorities that decide, not a general rule. Acute urinary retention or rapidly developing bone pain are matters for the emergency services in your country, immediately.
Further reading
- PSA and MRI, what 23 years of follow-up taught us
- Kidney stones, recurrence and the kidney
- Heart: 44% of people with hypertension do not know they have it
Sources
- Hamdy FC, Donovan JL, Lane JA, et al. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med, 2023;388:1547-1558. https://pubmed.ncbi.nlm.nih.gov/36912538/
- Hamdy FC, Donovan JL, Lane JA, et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med, 2016;375:1415-1424. https://pubmed.ncbi.nlm.nih.gov/27626136/
- Donovan JL, Hamdy FC, Lane JA, et al. Patient-reported outcomes 12 years after localized prostate cancer treatment. NEJM Evidence, 2023;2:EVIDoa2300018. https://pubmed.ncbi.nlm.nih.gov/38320051/
- Lane JA, Donovan JL, Young GJ, et al. Functional and quality of life outcomes of localised prostate cancer treatments, ProtecT. BJU Int, 2022;130:370-380. https://pubmed.ncbi.nlm.nih.gov/35373443/
- Neal DE, Metcalfe C, Donovan JL, et al. Ten-year mortality, disease progression and treatment-related side effects according to treatment received. Eur Urol, 2020;77:320-330. https://pubmed.ncbi.nlm.nih.gov/31771797/
- Bryant RJ, Oxley J, Young GJ, et al. The ProtecT trial, analysis of the patient cohort and baseline risk stratification. BJU Int, 2020;125:506-514. https://pubmed.ncbi.nlm.nih.gov/31900963/
- Wilt TJ, Brawer MK, Jones KM, et al. Radical prostatectomy versus observation for localized prostate cancer, PIVOT. N Engl J Med, 2012;367:203-213. https://pubmed.ncbi.nlm.nih.gov/22808955/
- Wilt TJ, Jones KM, Barry MJ, et al. Follow-up of prostatectomy versus observation for early prostate cancer. N Engl J Med, 2017;377:132-142. https://pubmed.ncbi.nlm.nih.gov/28700844/
- Wilt TJ, Vo TN, Langsetmo L, et al. Radical prostatectomy or observation, extended follow-up of PIVOT. Eur Urol, 2020;77:713-724. https://pubmed.ncbi.nlm.nih.gov/32089359/
- Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting, 29-year follow-up. N Engl J Med, 2018;379:2319-2329. https://pubmed.ncbi.nlm.nih.gov/30575473/
- Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med, 2014;370:932-942. https://pubmed.ncbi.nlm.nih.gov/24597866/
- Vernooij RWM, Lancee M, Cleves A, et al. Radical prostatectomy versus deferred treatment for localised prostate cancer. Cochrane Database Syst Rev, 2020;6:CD006590. https://pubmed.ncbi.nlm.nih.gov/32495338/
- Roobol MJ, de Vos II, Mansson M, et al. European study of prostate cancer screening, 23-year follow-up. N Engl J Med, 2025;393:1669-1680. https://pubmed.ncbi.nlm.nih.gov/41160819/
- Hugosson J, Roobol MJ, Mansson M, et al. A 16-year follow-up of the ERSPC. Eur Urol, 2019;76:43-51. https://pubmed.ncbi.nlm.nih.gov/30824296/
- Draisma G, Etzioni R, Tsodikov A, et al. Lead time and overdiagnosis in PSA screening. J Natl Cancer Inst, 2009;101:374-383. https://pubmed.ncbi.nlm.nih.gov/19276453/
- Gulati R, Inoue LY, Gore JL, Katcher J, Etzioni R. Individualized estimates of overdiagnosis in screen-detected prostate cancer. J Natl Cancer Inst, 2014;106:djt367. https://pubmed.ncbi.nlm.nih.gov/24399850/
- Klotz L, Vesprini D, Sethukavalan P, et al. Long-term follow-up of a large active surveillance cohort. J Clin Oncol, 2015;33:272-277. https://pubmed.ncbi.nlm.nih.gov/25512465/
- Tosoian JJ, Mamawala M, Epstein JI, et al. Intermediate and longer-term outcomes from a prospective active-surveillance program. J Clin Oncol, 2015;33:3379-3385. https://pubmed.ncbi.nlm.nih.gov/26324359/
- Bangma C, Doan P, Zhu L, et al. Has active surveillance for prostate cancer become safer? Lessons from a global clinical registry. Eur Urol Oncol, 2025;8:324-337. https://pubmed.ncbi.nlm.nih.gov/39025687/
- National Cancer Institute. SEER Cancer Stat Facts, prostate cancer. https://seer.cancer.gov/statfacts/html/prost.html
- NHS England, National Disease Registration Service. Cancer survival in England, cancers diagnosed 2018 to 2022. https://digital.nhs.uk/data-and-information/publications/statistical/cancer-survival-in-england/cancers-diagnosed-2018-to-2022-followed-up-to-2023/cancer-survival-by-stage
See also: all our articles on urology.
Have your case reviewed. Noria Health arranges a specialist consultation near Brussels and confirms feasibility within 24 to 48 hours. Open a case.