UpToDate
Official reprint from UpToDate®
www.uptodate.com ©2016 UpToDate®

External beam radiation therapy for localized prostate cancer

Authors
Steven J DiBiase, MD
Mack Roach, III, MD
Section Editors
Nicholas Vogelzang, MD
W Robert Lee, MD, MS, MEd
Jerome P Richie, MD, FACS
Deputy Editor
Michael E Ross, MD

INTRODUCTION

Standard options for the initial management of men with clinically localized prostate cancer (ie, without distant metastases) include radiation therapy (RT; external beam and/or brachytherapy, with or without androgen deprivation therapy [ADT]), radical prostatectomy, or active surveillance in carefully selected patients. The choice of treatment is determined by a variety of factors including patient preference, clinician judgment, and resource availability. (See "Initial approach to low- and very low-risk clinically localized prostate cancer" and "Initial approach to low- and very low-risk clinically localized prostate cancer", section on 'Choice of therapy'.)

Although there are few randomized trials comparing RT with radical prostatectomy, the trials completed to date and observational data suggest that outcomes with either external beam RT or brachytherapy using adequate dosing schedules and contemporary conformal techniques are similar to radical prostatectomy when men with clinically localized prostate cancer are stratified based upon clinical tumor (T) stage, pretreatment serum prostate-specific antigen (PSA), and Gleason score [1,2].

The use of external beam RT in the initial treatment of clinically localized prostate cancer will be reviewed here. The application of these techniques to men with low, intermediate, and high-risk prostate cancer is discussed separately, as is the role of brachytherapy. (See "Initial approach to low- and very low-risk clinically localized prostate cancer" and "Initial management of regionally localized intermediate, high, and very high-risk prostate cancer" and "Brachytherapy for localized prostate cancer".)

ANATOMIC CONSIDERATIONS

The goal of RT for men with localized prostate cancer is the delivery of a tumoricidal dose of radiation while minimizing radiation to surrounding normal tissues [3].

RT planning must take into account the volume and anatomic distribution of both the tumor and normal structures [4]. The prostate gland is a midline structure that lies in close proximity to the rectum and bladder. Thus, the major toxicities of normal tissue irradiation are gastrointestinal and genitourinary.

                                

Subscribers log in here

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information or to purchase a personal subscription, click below on the option that best describes you:
Literature review current through: Nov 2016. | This topic last updated: Thu Sep 29 00:00:00 GMT+00:00 2016.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2016 UpToDate, Inc.
References
Top
  1. Roach M 3rd, Ceron Lizarraga TL, Lazar AA. Radical Prostatectomy Versus Radiation and Androgen Deprivation Therapy for Clinically Localized Prostate Cancer: How Good Is the Evidence? Int J Radiat Oncol Biol Phys 2015; 93:1064.
  2. 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.
  3. Pollack JM. Radiation therapy options in the treatment of prostate cancer. Cancer Invest 2000; 18:66.
  4. McLaughlin PW, Troyer S, Berri S, et al. Functional anatomy of the prostate: implications for treatment planning. Int J Radiat Oncol Biol Phys 2005; 63:479.
  5. Michalski JM, Purdy JA, Winter K, et al. Preliminary report of toxicity following 3D radiation therapy for prostate cancer on 3DOG/RTOG 9406. Int J Radiat Oncol Biol Phys 2000; 46:391.
  6. Stephenson JA, Wiley AL Jr. Current techniques in three-dimensional CT simulation and radiation treatment planning. Oncology (Williston Park) 1995; 9:1225.
  7. Raboy A, Adler H, Albert P. Extraperitoneal endoscopic pelvic lymph node dissection: a review of 125 patients. J Urol 1997; 158:2202.
  8. Whitmore WF 3rd, Blute RD Jr, Kaplan WD, Gittes RF. Radiocolloid scintigraphic mapping of the lymphatic drainage of the prostate. J Urol 1980; 124:62.
  9. D'Amico AV, Whittington R, Malkowicz SB, et al. A multivariate analysis of clinical and pathological factors that predict for prostate specific antigen failure after radical prostatectomy for prostate cancer. J Urol 1995; 154:131.
  10. Partin AW, Kattan MW, Subong EN, et al. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA 1997; 277:1445.
  11. Morris DE, Emami B, Mauch PM, et al. Evidence-based review of three-dimensional conformal radiotherapy for localized prostate cancer: an ASTRO outcomes initiative. Int J Radiat Oncol Biol Phys 2005; 62:3.
  12. Bedford JL, Khoo VS, Webb S, Dearnaley DP. Optimization of coplanar six-field techniques for conformal radiotherapy of the prostate. Int J Radiat Oncol Biol Phys 2000; 46:231.
  13. Melian E, Mageras GS, Fuks Z, et al. Variation in prostate position quantitation and implications for three-dimensional conformal treatment planning. Int J Radiat Oncol Biol Phys 1997; 38:73.
  14. Nutting CM, Convery DJ, Cosgrove VP, et al. Reduction of small and large bowel irradiation using an optimized intensity-modulated pelvic radiotherapy technique in patients with prostate cancer. Int J Radiat Oncol Biol Phys 2000; 48:649.
  15. De Neve W, Claus F, Van Houtte P, et al. [Intensity modulated radiotherapy with dynamic multileaf collimator. Technique and clinical experience]. Cancer Radiother 1999; 3:378.
  16. Sheets NC, Goldin GH, Meyer AM, et al. Intensity-modulated radiation therapy, proton therapy, or conformal radiation therapy and morbidity and disease control in localized prostate cancer. JAMA 2012; 307:1611.
  17. Bauman G, Rumble RB, Chen J, et al. Intensity-modulated radiotherapy in the treatment of prostate cancer. Clin Oncol (R Coll Radiol) 2012; 24:461.
  18. Heidenreich A, Bastian PJ, Bellmunt J, et al. EAU guidelines on prostate cancer. part 1: screening, diagnosis, and local treatment with curative intent-update 2013. Eur Urol 2014; 65:124.
  19. Sanguineti G, Cavey ML, Endres EJ, et al. Is IMRT needed to spare the rectum when pelvic lymph nodes are part of the initial treatment volume for prostate cancer? Int J Radiat Oncol Biol Phys 2006; 64:151.
  20. Wang L, Hoban P, Paskalev K, et al. Dosimetric advantage and clinical implication of a micro-multileaf collimator in the treatment of prostate with intensity-modulated radiotherapy. Med Dosim 2005; 30:97.
  21. Wang-Chesebro A, Xia P, Coleman J, et al. Intensity-modulated radiotherapy improves lymph node coverage and dose to critical structures compared with three-dimensional conformal radiation therapy in clinically localized prostate cancer. Int J Radiat Oncol Biol Phys 2006; 66:654.
  22. Michalski JM, Yan Y, Watkins-Bruner D, et al. Preliminary toxicity analysis of 3-dimensional conformal radiation therapy versus intensity modulated radiation therapy on the high-dose arm of the Radiation Therapy Oncology Group 0126 prostate cancer trial. Int J Radiat Oncol Biol Phys 2013; 87:932.
  23. Zelefsky MJ, Levin EJ, Hunt M, et al. Incidence of late rectal and urinary toxicities after three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys 2008; 70:1124.
  24. Singh J, Greer PB, White MA, et al. Treatment-related morbidity in prostate cancer: a comparison of 3-dimensional conformal radiation therapy with and without image guidance using implanted fiducial markers. Int J Radiat Oncol Biol Phys 2013; 85:1018.
  25. Zelefsky MJ, Kollmeier M, Cox B, et al. Improved clinical outcomes with high-dose image guided radiotherapy compared with non-IGRT for the treatment of clinically localized prostate cancer. Int J Radiat Oncol Biol Phys 2012; 84:125.
  26. Aluwini S, Pos F, Schimmel E, et al. Hypofractionated versus conventionally fractionated radiotherapy for patients with prostate cancer (HYPRO): acute toxicity results from a randomised non-inferiority phase 3 trial. Lancet Oncol 2015; 16:274.
  27. Wortel RC, Incrocci L, Pos FJ, et al. Acute toxicity after image-guided intensity modulated radiation therapy compared to 3D conformal radiation therapy in prostate cancer patients. Int J Radiat Oncol Biol Phys 2015; 91:737.
  28. Peeters ST, Heemsbergen WD, van Putten WL, et al. Acute and late complications after radiotherapy for prostate cancer: results of a multicenter randomized trial comparing 68 Gy to 78 Gy. Int J Radiat Oncol Biol Phys 2005; 61:1019.
  29. Allen AM, Pawlicki T, Dong L, et al. An evidence based review of proton beam therapy: the report of ASTRO's emerging technology committee. Radiother Oncol 2012; 103:8.
  30. Yu JB, Soulos PR, Herrin J, et al. Proton versus intensity-modulated radiotherapy for prostate cancer: patterns of care and early toxicity. J Natl Cancer Inst 2013; 105:25.
  31. Coen JJ, Zietman AL, Rossi CJ, et al. Comparison of high-dose proton radiotherapy and brachytherapy in localized prostate cancer: a case-matched analysis. Int J Radiat Oncol Biol Phys 2012; 82:e25.
  32. Ishikawa H, Tsuji H, Kamada T, et al. Carbon-ion radiation therapy for prostate cancer. Int J Urol 2012; 19:296.
  33. Okada T, Tsuji H, Kamada T, et al. Carbon ion radiotherapy in advanced hypofractionated regimens for prostate cancer: from 20 to 16 fractions. Int J Radiat Oncol Biol Phys 2012; 84:968.
  34. Ishikawa H, Tsuji H, Kamada T, et al. Carbon ion radiation therapy for prostate cancer: results of a prospective phase II study. Radiother Oncol 2006; 81:57.
  35. Consensus statement: guidelines for PSA following radiation therapy. American Society for Therapeutic Radiology and Oncology Consensus Panel. Int J Radiat Oncol Biol Phys 1997; 37:1035.
  36. Roach M 3rd, Hanks G, Thames H Jr, et al. Defining biochemical failure following radiotherapy with or without hormonal therapy in men with clinically localized prostate cancer: recommendations of the RTOG-ASTRO Phoenix Consensus Conference. Int J Radiat Oncol Biol Phys 2006; 65:965.
  37. Crook JM, Malone S, Perry G, et al. Twenty-four-month postradiation prostate biopsies are strongly predictive of 7-year disease-free survival: results from a Canadian randomized trial. Cancer 2009; 115:673.
  38. Pollack A, Zagars GK, Antolak JA, et al. Prostate biopsy status and PSA nadir level as early surrogates for treatment failure: analysis of a prostate cancer randomized radiation dose escalation trial. Int J Radiat Oncol Biol Phys 2002; 54:677.
  39. Vance W, Tucker SL, de Crevoisier R, et al. The predictive value of 2-year posttreatment biopsy after prostate cancer radiotherapy for eventual biochemical outcome. Int J Radiat Oncol Biol Phys 2007; 67:828.
  40. Michalski JM, Moughan J, Purdy J, et al. randomized trial of 79.2Gy versus 70.2Gy radiation therapy (RT) for localized prostate cancer. J Clin Oncol 33, 2015 (suppl 7; abstr 4)
  41. Lee WR. Seduced by dose? J Clin Oncol 2010; 28:1087.
  42. Speight JL, Roach M 3rd. Radiotherapy in the management of clinically localized prostate cancer: evolving standards, consensus, controversies and new directions. J Clin Oncol 2005; 23:8176.
  43. Eade TN, Hanlon AL, Horwitz EM, et al. What dose of external-beam radiation is high enough for prostate cancer? Int J Radiat Oncol Biol Phys 2007; 68:682.
  44. Thames HD, Kuban D, Levy LB, et al. The role of overall treatment time in the outcome of radiotherapy of prostate cancer: an analysis of biochemical failure in 4839 men treated between 1987 and 1995. Radiother Oncol 2010; 96:6.
  45. Lee WR. Prostate cancer and the hypofractionation hypothesis. J Clin Oncol 2013; 31:3849.
  46. Incrocci L, Wortel RC, Aluwini SA,et al. Hypofractionated vs Conventionally Fractionated Radiotherapy for Prostate Cancer: 5-year Oncologic Outcomes of the Dutch Randomized Phase 3 HYPRO Trial (Abstract LBA2). ASTRO 2015 meeting.
  47. Dearnaley D, et al. Five year outcomes of aphase 3 randomized trial of conventional or hypofractionated high dose intensity modulated radiotherapy for prostate cancer (CRUK/06/016): CHHiP investigators group. (Abstract 8LBA). European Cancer Congress 2015.
  48. Lee WR, Dignam JJ, Amin MB, et al. Randomized Phase III Noninferiority Study Comparing Two Radiotherapy Fractionation Schedules in Patients With Low-Risk Prostate Cancer. J Clin Oncol 2016; 34:2325.
  49. Catton CN, Lukka H, Julian JA, et al. A randomized trial of a shorter radiation fractionation schedule for the treatment of localized prostate cancer. Abstract 5003 American Society of Clinical Oncology 2016 meeting.
  50. Incrocci L, Wortel RC, Alemayehu WG, et al. Hypofractionated versus conventionally fractionated radiotherapy for patients with localised prostate cancer (HYPRO): final efficacy results from a randomised, multicentre, open-label, phase 3 trial. Lancet Oncol 2016; 17:1061.
  51. Dearnaley D, Syndikus I, Mossop H, et al. Conventional versus hypofractionated high-dose intensity-modulated radiotherapy for prostate cancer: 5-year outcomes of the randomised, non-inferiority, phase 3 CHHiP trial. Lancet Oncol 2016; 17:1047.
  52. http://www.astro.org/uploadedFiles/Main_Site/Practice_Management/Reimbursement/2013HPcoding%20guidelines_SBRT_Final.pdf (Accessed on December 10, 2013).
  53. King CR, Collins S, Fuller D, et al. Health-related quality of life after stereotactic body radiation therapy for localized prostate cancer: results from a multi-institutional consortium of prospective trials. Int J Radiat Oncol Biol Phys 2013; 87:939.
  54. King CR, Freeman D, Kaplan I, et al. Stereotactic body radiotherapy for localized prostate cancer: pooled analysis from a multi-institutional consortium of prospective phase II trials. Radiother Oncol 2013; 109:217.
  55. Yu JB, Cramer LD, Herrin J, et al. Stereotactic body radiation therapy versus intensity-modulated radiation therapy for prostate cancer: comparison of toxicity. J Clin Oncol 2014; 32:1195.
  56. Roach M 3rd, Marquez C, Yuo HS, et al. Predicting the risk of lymph node involvement using the pre-treatment prostate specific antigen and Gleason score in men with clinically localized prostate cancer. Int J Radiat Oncol Biol Phys 1994; 28:33.
  57. Seaward SA, Weinberg V, Lewis P, et al. Improved freedom from PSA failure with whole pelvic irradiation for high-risk prostate cancer. Int J Radiat Oncol Biol Phys 1998; 42:1055.
  58. Cox JD, Stetz J, Pajak TF. Toxicity criteria of the Radiation Therapy Oncology Group (RTOG) and the European Organization for Research and Treatment of Cancer (EORTC). Int J Radiat Oncol Biol Phys 1995; 31:1341.
  59. Talcott JA, Rieker P, Clark JA, et al. Patient-reported symptoms after primary therapy for early prostate cancer: results of a prospective cohort study. J Clin Oncol 1998; 16:275.
  60. Shipley WU, Zietman AL, Hanks GE, et al. Treatment related sequelae following external beam radiation for prostate cancer: a review with an update in patients with stages T1 and T2 tumor. J Urol 1994; 152:1799.
  61. Haddock MG, Sloan JA, Bollinger JW, et al. Patient assessment of bowel function during and after pelvic radiotherapy: results of a prospective phase III North Central Cancer Treatment Group clinical trial. J Clin Oncol 2007; 25:1255.
  62. Zietman AL, DeSilvio ML, Slater JD, et al. Comparison of conventional-dose vs high-dose conformal radiation therapy in clinically localized adenocarcinoma of the prostate: a randomized controlled trial. JAMA 2005; 294:1233.
  63. Peeters ST, Heemsbergen WD, Koper PC, et al. Dose-response in radiotherapy for localized prostate cancer: results of the Dutch multicenter randomized phase III trial comparing 68 Gy of radiotherapy with 78 Gy. J Clin Oncol 2006; 24:1990.
  64. Dearnaley DP, Hall E, Lawrence D, et al. Phase III pilot study of dose escalation using conformal radiotherapy in prostate cancer: PSA control and side effects. Br J Cancer 2005; 92:488.
  65. Beckendorf V, Guérif S, Le Prisé E, et al. The GETUG 70 Gy vs. 80 Gy randomized trial for localized prostate cancer: feasibility and acute toxicity. Int J Radiat Oncol Biol Phys 2004; 60:1056.
  66. Ryu JK, Winter K, Michalski JM, et al. Interim report of toxicity from 3D conformal radiation therapy (3D-CRT) for prostate cancer on 3DOG/RTOG 9406, level III (79.2 Gy). Int J Radiat Oncol Biol Phys 2002; 54:1036.
  67. Zelefsky MJ, Fuks Z, Hunt M, et al. High dose radiation delivered by intensity modulated conformal radiotherapy improves the outcome of localized prostate cancer. J Urol 2001; 166:876.
  68. Hamilton AS, Stanford JL, Gilliland FD, et al. Health outcomes after external-beam radiation therapy for clinically localized prostate cancer: results from the Prostate Cancer Outcomes Study. J Clin Oncol 2001; 19:2517.
  69. Potosky AL, Legler J, Albertsen PC, et al. Health outcomes after prostatectomy or radiotherapy for prostate cancer: results from the Prostate Cancer Outcomes Study. J Natl Cancer Inst 2000; 92:1582.
  70. Potosky AL, Davis WW, Hoffman RM, et al. Five-year outcomes after prostatectomy or radiotherapy for prostate cancer: the prostate cancer outcomes study. J Natl Cancer Inst 2004; 96:1358.
  71. Chen RC, Clark JA, Talcott JA. Individualizing quality-of-life outcomes reporting: how localized prostate cancer treatments affect patients with different levels of baseline urinary, bowel, and sexual function. J Clin Oncol 2009; 27:3916.
  72. Elliott SP, Meng MV, Elkin EP, et al. Incidence of urethral stricture after primary treatment for prostate cancer: data From CaPSURE. J Urol 2007; 178:529.
  73. Lawton CA, Won M, Pilepich MV, et al. Long-term treatment sequelae following external beam irradiation for adenocarcinoma of the prostate: analysis of RTOG studies 7506 and 7706. Int J Radiat Oncol Biol Phys 1991; 21:935.
  74. Choe KS, Jani AB, Liauw SL. External beam radiotherapy for prostate cancer patients on anticoagulation therapy: how significant is the bleeding toxicity? Int J Radiat Oncol Biol Phys 2010; 76:755.
  75. Alemozaffar M, Regan MM, Cooperberg MR, et al. Prediction of erectile function following treatment for prostate cancer. JAMA 2011; 306:1205.
  76. Mantz CA, Song P, Farhangi E, et al. Potency probability following conformal megavoltage radiotherapy using conventional doses for localized prostate cancer. Int J Radiat Oncol Biol Phys 1997; 37:551.
  77. Roach M 3rd, Nam J, Gagliardi G, et al. Radiation dose-volume effects and the penile bulb. Int J Radiat Oncol Biol Phys 2010; 76:S130.
  78. Fisch BM, Pickett B, Weinberg V, Roach M. Dose of radiation received by the bulb of the penis correlates with risk of impotence after three-dimensional conformal radiotherapy for prostate cancer. Urology 2001; 57:955.
  79. Roach M, Winter K, Michalski JM, et al. Penile bulb dose and impotence after three-dimensional conformal radiotherapy for prostate cancer on RTOG 9406: findings from a prospective, multi-institutional, phase I/II dose-escalation study. Int J Radiat Oncol Biol Phys 2004; 60:1351.
  80. Wernicke AG, Valicenti R, Dieva K, et al. Radiation dose delivered to the proximal penis as a predictor of the risk of erectile dysfunction after three-dimensional conformal radiotherapy for localized prostate cancer. Int J Radiat Oncol Biol Phys 2004; 60:1357.
  81. Rivin del Campo E, Thomas K, Weinberg V, Roach M 3rd. Erectile dysfunction after radiotherapy for prostate cancer: a model assessing the conflicting literature on dose-volume effects. Int J Impot Res 2013; 25:161.
  82. Buyyounouski MK, Horwitz EM, Price RA, et al. Intensity-modulated radiotherapy with MRI simulation to reduce doses received by erectile tissue during prostate cancer treatment. Int J Radiat Oncol Biol Phys 2004; 58:743.
  83. Incrocci L, Koper PC, Hop WC, Slob AK. Sildenafil citrate (Viagra) and erectile dysfunction following external beam radiotherapy for prostate cancer: a randomized, double-blind, placebo-controlled, cross-over study. Int J Radiat Oncol Biol Phys 2001; 51:1190.
  84. Incrocci L, Slagter C, Slob AK, Hop WC. A randomized, double-blind, placebo-controlled, cross-over study to assess the efficacy of tadalafil (Cialis) in the treatment of erectile dysfunction following three-dimensional conformal external-beam radiotherapy for prostatic carcinoma. Int J Radiat Oncol Biol Phys 2006; 66:439.
  85. Watkins Bruner D, James JL, Bryan CJ, et al. Randomized, double-blinded, placebo-controlled crossover trial of treating erectile dysfunction with sildenafil after radiotherapy and short-term androgen deprivation therapy: results of RTOG 0215. J Sex Med 2011; 8:1228.
  86. Yang L, Qian S, Liu L, et al. Phosphodiesterase-5 inhibitors could be efficacious in the treatment of erectile dysfunction after radiotherapy for prostate cancer: a systematic review and meta-analysis. Urol Int 2013; 90:339.
  87. Pisansky TM, Pugh SL, Greenberg RE, et al. Tadalafil for prevention of erectile dysfunction after radiotherapy for prostate cancer: the Radiation Therapy Oncology Group [0831] randomized clinical trial. JAMA 2014; 311:1300.
  88. Zelefsky MJ, Shasha D, Branco RD, et al. Prophylactic sildenafil citrate improves select aspects of sexual function in men treated with radiotherapy for prostate cancer. J Urol 2014; 192:868.
  89. Danjoux C, Gardner S, Fitch M. Prospective evaluation of fatigue during a course of curative radiotherapy for localised prostate cancer. Support Care Cancer 2007; 15:1169.
  90. Truong PT, Berthelet E, Lee JC, et al. Prospective evaluation of the prevalence and severity of fatigue in patients with prostate cancer undergoing radical external beam radiotherapy and neoadjuvant hormone therapy. Can J Urol 2006; 13:3139.
  91. Windsor PM, Nicol KF, Potter J. A randomized, controlled trial of aerobic exercise for treatment-related fatigue in men receiving radical external beam radiotherapy for localized prostate carcinoma. Cancer 2004; 101:550.
  92. Segal RJ, Reid RD, Courneya KS, et al. Randomized controlled trial of resistance or aerobic exercise in men receiving radiation therapy for prostate cancer. J Clin Oncol 2009; 27:344.
  93. Iğdem S, Alço G, Ercan T, et al. Insufficiency fractures after pelvic radiotherapy in patients with prostate cancer. Int J Radiat Oncol Biol Phys 2010; 77:818.
  94. Kwon JW, Huh SJ, Yoon YC, et al. Pelvic bone complications after radiation therapy of uterine cervical cancer: evaluation with MRI. AJR Am J Roentgenol 2008; 191:987.
  95. Murray L, Henry A, Hoskin P, et al. Second primary cancers after radiation for prostate cancer: a systematic review of the clinical data and impact of treatment technique. Radiother Oncol 2014; 110:213.
  96. Eifler JB, Humphreys EB, Agro M, et al. Causes of death after radical prostatectomy at a large tertiary center. J Urol 2012; 188:798.
  97. Mukherjee S, Reddy CA, Ciezki JP, et al. Risk for developing myelodysplastic syndromes in prostate cancer patients definitively treated with radiation. J Natl Cancer Inst 2014; 106:djt462.
  98. Donovan JL, Hamdy FC, Lane JA, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med 2106.
  99. Lennernäs B, Majumder K, Damber JE, et al. Radical prostatectomy versus high-dose irradiation in localized/locally advanced prostate cancer: A Swedish multicenter randomized trial with patient-reported outcomes. Acta Oncol 2015; 54:875.