Prostate Radiotherapy
Prostate SBRT or Surgery? What PACE-A Says About Quality of Life
PACE-A compared patient-reported urinary, bowel, and sexual outcomes after prostate SBRT and prostatectomy for localized prostate cancer.
Short answer: PACE-A found that prostate SBRT and surgery produced different quality-of-life tradeoffs. At two years, people assigned to surgery reported more urinary pad use and worse sexual-function scores; people assigned to SBRT reported somewhat more bowel bother. The trial does not establish one universally superior treatment.
What was compared?
PACE-A randomized 123 people with localized low- or intermediate-risk prostate cancer to prostatectomy or five-treatment SBRT. Most had intermediate-risk disease. Hormone therapy was not used.
Enrollment stopped early after pandemic-related disruption, and not every participant completed the two-year questionnaires. Those limitations make the randomized comparison valuable but less definitive than a larger completed trial.
What did patients report?
At two years:
- 50% of evaluated surgery participants and 6.5% of evaluated SBRT participants used at least one urinary pad daily.
- Bowel-domain scores were modestly better after surgery.
- Sexual-function scores were worse after surgery.
These outcomes describe groups, not a guaranteed experience. Surgical technique, radiation planning, age, baseline function, medications, and recovery support all influence individual results.
Why patient reports matter
Clinician-graded toxicity was uncommon in both groups, yet questionnaires detected meaningful differences. A symptom can affect daily life even when it does not meet a clinician's threshold for a higher toxicity grade.
This is why treatment discussions should include patient-reported outcomes rather than only recurrence statistics.
What PACE-A does not answer
PACE-A was not designed to prove that SBRT and surgery have identical long-term cancer control. Its population also does not represent every person with high-risk disease, major urinary obstruction, prior pelvic treatment, or significant medical illness.
Other options—including active surveillance, longer-course radiation, brachytherapy, and radiation with hormone therapy—may be appropriate depending on risk.
A better way to compare choices
Ask each specialist to explain:
- the expected cancer-control benefit for your risk group;
- your baseline urinary, bowel, and sexual function;
- how recovery time and treatment visits affect you;
- whether hormone therapy is recommended;
- what salvage options remain after each treatment; and
- which outcome you most want to preserve.
PACE-A is most useful as a shared decision-making tool. It shows that localized prostate cancer treatment is not simply “surgery versus radiation”—it is a choice among different patterns of benefit, burden, and side effects.
Questions patients often ask
Did PACE-A prove SBRT is better than surgery?
No. It found different patient-reported side-effect patterns. It was not large enough to settle every cancer-control or quality-of-life question.
Who was included?
Participants had low- or intermediate-risk localized disease, and hormone therapy was not permitted. Results should not be generalized automatically to high-risk cancer.
Why do baseline symptoms matter?
Urinary, bowel, and sexual function before treatment strongly affect what changes a person may notice and which tradeoffs matter most.
Sources and further reading
- Radical Prostatectomy Versus Stereotactic Radiotherapy for Clinically Localised Prostate Cancer. European Urology (2024).
- Phase 3 Trial of Stereotactic Body Radiotherapy in Localized Prostate Cancer. The New England Journal of Medicine (2024).
