The Headline: Ultra-hypofractionated radiotherapy is associated with substantially less urinary incontinence and patient-reported sexual dysfunction than radical prostatectomy.
The Study: The long-awaited phase 3 PACE-A trial randomized 123 surgical candidates with localized prostate cancer (cT1-T2, Gleason ≤3+4, PSA ≤20 ng/mL) to ultra-hypofractionated radiotherapy (36.25 Gy/5 no boost) versus radical prostatectomy (robotic or laparoscopic) with no ADT permitted. At a median follow-up of 8 years, only 13 biochemical/clinical failure events had occurred: 5 with radiotherapy and 8 with prostatectomy. Freedom from biochemical or clinical failure at 5 years was 95% versus 94%, respectively, and at 8 years 91% versus 84%. The trial was not powered for noninferiority, so while both approaches demonstrated excellent long-term control, these data do not establish equivalence. Where the difference was apparent: at 5 years, ≥1 urinary pad was reported by 8% of SBRT patients versus 48% after prostatectomy. Sexual function likewise favored radiotherapy, with patient reported sexual health scores falling from 79 to 58 (-17) versus 62 to 17 (-42) after prostatectomy. Median patient-reported erectile function scores at 5 years were 19 (mild) versus 5 (severe).
TBL: PACE-A gives us the long-term randomized comparison patients have been waiting for: both prostatectomy and ultra-hypofractionated radiotherapy provide excellent disease control with a clear divergence of urinary and sexual side effects. | van As, ASTRO 2026
The Study: The long-awaited phase 3 PACE-A trial randomized 123 surgical candidates with localized prostate cancer (cT1-T2, Gleason ≤3+4, PSA ≤20 ng/mL) to ultra-hypofractionated radiotherapy (36.25 Gy/5 no boost) versus radical prostatectomy (robotic or laparoscopic) with no ADT permitted. At a median follow-up of 8 years, only 13 biochemical/clinical failure events had occurred: 5 with radiotherapy and 8 with prostatectomy. Freedom from biochemical or clinical failure at 5 years was 95% versus 94%, respectively, and at 8 years 91% versus 84%. The trial was not powered for noninferiority, so while both approaches demonstrated excellent long-term control, these data do not establish equivalence. Where the difference was apparent: at 5 years, ≥1 urinary pad was reported by 8% of SBRT patients versus 48% after prostatectomy. Sexual function likewise favored radiotherapy, with patient reported sexual health scores falling from 79 to 58 (-17) versus 62 to 17 (-42) after prostatectomy. Median patient-reported erectile function scores at 5 years were 19 (mild) versus 5 (severe).
TBL: PACE-A gives us the long-term randomized comparison patients have been waiting for: both prostatectomy and ultra-hypofractionated radiotherapy provide excellent disease control with a clear divergence of urinary and sexual side effects. | van As, ASTRO 2026