***TASK*** the task is to summarize an input biomedical literature in six sentences 
    ***INPUT*** the input is a biomedical literature 
    ***OUTPUT*** the output is the summary of an input biomedical literature in six sentences 
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    Input: BACKGROUND The comparative effectiveness of treatments for prostate cancer that is detected by prostate-specific antigen ( PSA ) testing remains uncertain . METHODS We compared active monitoring , radical prostatectomy , and external-beam radiotherapy for the treatment of clinical ly localized prostate cancer . Between 1999 and 2009 , a total of 82,429 men 50 to 69 years of age received a PSA test ; 2664 received a diagnosis of localized prostate cancer , and 1643 agreed to undergo r and omization to active monitoring ( 545 men ) , surgery ( 553 ) , or radiotherapy ( 545 ) . The primary outcome was prostate-cancer mortality at a median of 10 years of follow-up . Secondary outcomes included the rates of disease progression , metastases , and all-cause deaths . RESULTS There were 17 prostate-cancer-specific deaths overall : 8 in the active-monitoring group ( 1.5 deaths per 1000 person-years ; 95 % confidence interval [ CI ] , 0.7 to 3.0 ) , 5 in the surgery group ( 0.9 per 1000 person-years ; 95 % CI , 0.4 to 2.2 ) , and 4 in the radiotherapy group ( 0.7 per 1000 person-years ; 95 % CI , 0.3 to 2.0 ) ; the difference among the groups was not significant ( P=0.48 for the overall comparison ) . In addition , no significant difference was seen among the groups in the number of deaths from any cause ( 169 deaths overall ; P=0.87 for the comparison among the three groups ) . Metastases developed in more men in the active-monitoring group ( 33 men ; 6.3 events per 1000 person-years ; 95 % CI , 4.5 to 8.8 ) than in the surgery group ( 13 men ; 2.4 per 1000 person-years ; 95 % CI , 1.4 to 4.2 ) or the radiotherapy group ( 16 men ; 3.0 per 1000 person-years ; 95 % CI , 1.9 to 4.9 ) ( P=0.004 for the overall comparison ) . Higher rates of disease progression were seen in the active-monitoring group ( 112 men ; 22.9 events per 1000 person-years ; 95 % CI , 19.0 to 27.5 ) than in the surgery group ( 46 men ; 8.9 events per 1000 person-years ; 95 % CI , 6.7 to 11.9 ) or the radiotherapy group ( 46 men ; 9.0 events per 1000 person-years ; 95 % CI , 6.7 to 12.0 ) ( P<0.001 for the overall comparison ) . CONCLUSIONS At a median of 10 years , prostate-cancer-specific mortality was low irrespective of the treatment assigned , with no significant difference among treatments . Surgery and radiotherapy were associated with lower incidences of disease progression and metastases than was active monitoring . ( Funded by the National Institute for Health Research ; ProtecT Current Controlled Trials number , IS RCT N20141297 ; Clinical Trials.gov number , NCT02044172 . ) OBJECTIVES Establishing realistic health-related quality -of-life  ( HRQOL ) expectations before the choice of cancer treatment is made is an important goal of patient counseling . We prospect ively studied the pretreatment expectations of prostate cancer-specific HRQOL with an adapted Exp and ed Prostate Cancer Index Composite instrument . METHODS Baseline pretreatment Exp and ed Prostate Cancer Index Composite scores , pretreatment expectation scores , and 1-year posttreatment scores were prospect ively collected for 50 patients undergoing radical prostatectomy or external beam radiotherapy .  The pretreatment expectations and observed HRQOL scores at 1 year after treatment were compared for the urinary incontinence , urinary irritation , bowel , sexual , and hormonal domains . RESULTS The expectation scores did not differ from the HRQOL scores at 1 year for urinary irritation , bowel function , and the hormonal domain . However , the sexual domain expectations were 22.5 % greater than observed sexual domain scores 1 year after treatment ( P < 0.0001 , 99 % confidence interval 11 to 34 ) for both surgery and radiotherapy subjects . Anxiety , depression , education level , and income did not correlate with the expectations for HRQOL outcomes . A modest correlation was found between optimism and greater expectations for the sexual domain ( Pearson correlation coefficient 0.38 , P < 0.001 ) . CONCLUSIONS Measuring HRQOL expectations before treatment may eluci date discrepancies between patient expectations and observed outcomes . This pilot study found that patients ' expectations regarding urinary and bowel outcomes more closely reflected their eventual observed outcome than did their expectations regarding sexual outcome BACKGROUND Most localized prostate cancers are believed to have an indolent course . Within 15 yr of diagnosis , most deaths among men with prostate cancer ( PCa ) can be attributed to other competing causes . However , data from studies with extended follow-up are insufficient to determine appropriate treatment for men with localized disease . OBJECTIVE To investigate the long-term natural history of untreated , early-stage PCa . DESIGN , SETTING , AND PARTICIPANTS We conducted a population -based , prospect ive-cohort study using a consecutive sample of 223 patients with untreated , localized PCa from a regionally well-defined catchment area in central Sweden . All subjects were initially managed with observation . And rogen deprivation therapy was administered when symptomatic tumor progression occurred . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS Based on > 30 yr of follow-up , the main outcome measures were : progression-free , cause-specific , and overall survival , and rates of progression and mortality per 1000 person-years . RESULTS AND LIMITATIONS After 32 yr of follow-up , all but 3 ( 1 % ) of the 223 men had died . We observed 90 ( 41.4 % ) local progression events and 41 ( 18.4 % ) cases of progression to distant metastasis . In total , 38 ( 17 % ) men died of PCa . Cause-specific survival decreased between 15 and 20 yr , but stabilized with further follow-up . All nine men with Gleason grade 8 - 10 disease died within the first 10 yr of follow-up , five ( 55 % ) from PCa . Survival for men with well-differentiated , nonpalpable tumors declined slowly through 20 yr , and more rapidly between 20 and 25 yr ( from 75.2 % [ 95 % confidence interval , 48.4 - 89.3 ] to 25 % [ 95 % confidence interval , 22.0 - 72.5 ] ) . It is unclear whether these data are relevant for tumors detected by elevated prostate-specific antigen levels . CONCLUSIONS Although localized PCa most often has an indolent course , local progression and distant metastasis can develop over the long term , even among patients considered low risk at diagnosis For patients with low‐risk prostate cancer ( PCa ) , active surveillance ( AS ) may produce oncologic outcomes comparable to those achieved with radical prostatectomy ( RP ) . Health‐related quality ‐of‐life ( HRQoL ) outcomes are important to consider , yet few studies have examined HRQoL among patients with PCa who were managed with AS . In this study , the authors compared longitudinal HRQoL in a prospect i ve , racially diverse , and contemporary cohort of patients who underwent RP or AS for low‐risk PCa PURPOSE Earlier studies evaluating the effect on quality of life ( QoL ) of localized prostate cancer interventions included patients receiving adjuvant hormone therapy , which could have affected their outcomes . Our objective was to compare the QoL impact of the three most common primary treatments on patients who were not receiving adjuvant hormonal treatment .  PATIENTS AND METHODS This was a prospect i ve study of 435 patients treated with radical prostatectomy , external-beam radiotherapy , or brachytherapy .  QoL was assessed before and after treatment with the Short Form-36 and the Exp and ed Prostate Cancer Index Composite . Differences between groups were tested by analysis of variance . Distribution of outcome at 3 years was examined by stratifying according to baseline status . Generalized estimating equation models were constructed to assess the effect of treatment over time . RESULTS Compared with the brachytherapy group , the prostatectomy group showed greater deterioration on urinary incontinence and sexual scores but better urinary irritative-obstructive results ( -18.22 , -13.19 , and + 6.38 , respectively , at 3 years ; P < .001 ) . In patients with urinary irritative-obstructive symptoms at baseline , improvement was observed in 64 % of those treated with nerve-sparing radical prostatectomy . Higher bowel worsening ( -2.87 , P = .04 ) was observed in the external radiotherapy group , with 20 % of patients reporting bowel symptoms . CONCLUSION Radical prostatectomy caused urinary incontinence and sexual dysfunction but improved pre-existing urinary irritative-obstructive symptoms .  External radiotherapy and brachytherapy caused urinary irritative-obstructive adverse effects and some sexual dysfunction .  External radiotherapy also caused bowel adverse effects . Relevant differences between treatment groups persisted for up to 3 years of follow-up , although the difference in sexual adverse effects between brachytherapy and prostatectomy tended to decline over long-term follow-up . These results provide valuable information for clinical decision making PURPOSE The American College of Surgeons Oncology Group phase III Surgical Prostatectomy Versus Interstitial Radiation Intervention Trial comparing  radical prostatectomy ( RP ) and brachytherapy ( BT )  closed after 2 years due to poor accrual . We report health-related quality of life ( HRQOL ) at a mean of 5.3 years for 168 trial-eligible men who either chose or were r and omly assigned to RP or BT following a multidisciplinary educational session .  PATIENTS AND METHODS After initial lack of accrual , a multidisciplinary educational session was introduced for eligible patients . In all , 263 men attended 47 sessions . Of those , 34 consented to r and om assignment , 62 chose RP , and 94 chose BT . Five years later , these 190 men underwent HRQOL evaluation by using the cancer-specific 50-item Exp and ed Prostate Cancer Index Composite , the Short Form 12 Physical Component Score , and Short Form 12 Mental Component Score . Response rate was 88.4 % . The Wilcoxon rank sum test was used to compare summary scores between the two interventions . RESULTS Of 168 survey responders , 60.7 % had BT ( 9.5 % r and omly assigned ) and 39.3 % had RP ( 9.5 % r and omly assigned ) .  Median age was 61.4 years for BT and 59.4 for RP ( P = .05 ) . Median follow-up was 5.2 years ( range , 3.2 to 6.5 years ) . For BT versus RP , there was no difference in bowel or hormonal domains , but men treated with BT scored better in urinary ( 91.8 v 88.1 ; P = .02 ) and sexual ( 52.5 v 39.2 ; P = .001 ) domains , and in patient satisfaction ( 93.6 v 76.9 ; P < .001 ) . CONCLUSION Although treatment allocation was r and om in only 19 % , all patients received identical information in a multidisciplinary setting before selecting RP , BT , or r and om assignment . HRQOL evaluated 3.2 to 6.5 years after treatment showed an advantage for BT in urinary and sexual domains and in patient satisfaction BACKGROUND AND PURPOSE The aim of the study was to compare quality of life after permanent  I-125 brachytherapy ( BT ) and external beam radiotherapy ( EBRT )  for prostate cancer . MATERIAL S AND METHODS A group of 104 patients ( 52 in each group ) have been surveyed prospect ively before  EBRT/BT  ( time A ) , at the last day of EBRT ( 70.2 - 72.0 Gy ) or one month after BT ( time B ) , and a median time of 16 months after EBRT/BT ( time C ) using a vali date d question naire ( Exp and ed Prostate Cancer Index Composite ) . Pairs were matched according to the following criteria : age + /-5 years , prostate volume + /-10 cc , use of anti and rogens , and erectile function . RESULTS Urinary function/bother scores decreased significantly more after BT both at time B and time C. Bowel function/bother scores tended to be higher after BT , with a lower percentage of patients with painful bowel movements ( BT : 12%/27%/15 % ; EBRT : 19%/52%/35 % at time A/B/C ; p<0.05 for differences at times B/C ) and rectal bleeding ( BT : 12%/12%/12 % ; EBRT : 8%/14%/17 % ) 
    Output:
    
For a follow-up of up to 6 yr , active surveillance was found to have the lowest impact on cancer-specific QoL , surgery had a negative impact on urinary and sexual function when compared with active surveillance and EBRT , and EBRT had a negative impact on bowel function when compared with active surveillance and surgery .
This is the first systematic review comparing the impact of different primary treatments on cancer-specific QoL for men with clinical ly localised prostate cancer , using vali date d cancer-specific patient-reported outcome measures only .
PATIENT SUMMARY Our review of the current evidence suggests that for a period of up to 6 yr after treatment , men with localised prostate cancer who were managed with active surveillance reported high levels of quality of life ( QoL ) .
Men treated with surgery reported mainly urinary and sexual problems , while those treated with external beam radiotherapy reported mainly bowel problems .
Men eligible for  brachytherapy reported urinary problems up to a year after therapy , but then their QoL returned gradually to as it was before treatment