***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 
    ***DOCUMENTATION*** 
    ***EXAMPLES*** 
    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 . ) 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 BACKGROUND Initial treatment options for low-risk clinical ly localized prostate cancer ( PCa ) include radical prostatectomy ( RP ) or observation . OBJECTIVE To examine cancer-specific mortality ( CSM ) after accounting for other-cause mortality ( OCM ) in PCa patients treated with either RP or observation .  DESIGN , SETTING , AND PARTICIPANTS Using the Surveillance Epidemiology and End Results Medicare-linked data base , a total of 44 694 patients ≥65 yr with localized ( T1/2 ) PCa were identified ( 1992 - 2005 ) . INTERVENTION RP and observation . MEASUREMENTS Propensity-score matching was used to adjust for potential selection biases associated with treatment type . The matched cohort was r and omly divided into the development and validation sets . Competing-risks regression models were fitted and a competing-risks nomogram was developed and externally vali date d. RESULTS AND LIMITATIONS Overall , 22,244 ( 49.8 % ) patients were treated with RP versus 22450 ( 50.2 % ) with observation . Propensity score-matched analyses derived 11,669 matched pairs . In the development cohort , the 10-yr CSM rate was 2.8 % ( 2.3 - 3.5 % ) for RP versus 5.8 % ( 5.0 - 6.6 % ) for observation ( absolute risk reduction : 3.0 % ; relative risk reduction : 0.5 % ; p<0.001 ) . In multivariable analyses , the CSM hazard ratio for RP was 0.48 ( 0.38 - 0.59 ) relative to observation ( p<0.001 ) . The competing-risks nomogram discrimination was 73 % and 69 % for prediction of CSM and OCM , respectively , in external validation . The nature of observational data may have introduced a selection bias . CONCLUSIONS On average RP reduces the risk of CSM by half in patients aged ≥65 yr , relative to observation . The individualized protective effect of RP relative to observation may be quantified with our nomogram OBJECTIVE To assess the reasons for the dramatic surge in prostate cancer incidence from 1986 to 1991 . DESIGN Population -based study of incidence rates and procedures used to detect and diagnose prostate cancer derived from Medicare cl aims data and the National Cancer Institute 's Surveillance , Epidemiology , and End Results ( SEER ) program from 1986 to 1991 . SETTING Four SEER areas ( Connecticut ; Atlanta , Ga ; Detroit , Mich ; and Seattle -- Puget Sound , Wash ) covering approximately 6 % of the US population . PARTICIPANTS A 5 % r and om sample of male fee-for-service Medicare beneficiaries aged 65 years and older without cancer , and all men with prostate cancer diagnosed at 65 years of age and older residing in the four areas . MAIN OUTCOME MEASURES The age-adjusted rates of prostate cancer incidence , prostate needle biopsy , transurethral resection of the prostate , serum prostate-specific antigen ( PSA ) testing , and transrectal ultrasound .  RESULTS The age-adjusted incidence rate of prostate cancer among men aged 65 years and older in the four SEER areas rose 82 % from 1986 to 1991 , with the largest annual increases occurring in 1990 ( 20 % ) and 1991 ( 19 % ) . Prostate needle biopsy rates increased while the use of transurethral resection of the prostate declined from 1986 to 1991 . The rising needle biopsy rate has been driven by an exponential increase in PSA testing in the general population from 1988 to 1991 and , to a much lesser extent , the increasing use of transrectal ultrasound since 1986 . The use of PSA or transrectal ultrasound  has increased across age and race groups and in different geographic areas . However , there remain wide geographic variations in the use of PSA screening . CONCLUSIONS The recent dramatic epidemic of prostate cancer is likely the result of the increasing detection of tumors result ing from increased PSA screening . The magnitude and rapidity of the incidence rise suggest that changes in the intensity of medical surveillance is the most plausible explanation for this trend . IMPLICATION S The rapid diffusion of screening interventions that have the ability to detect latent asymptomatic disease leads to important concerns regarding costs and patient quality of life for men aged 65 years and older . Geographic variability in the adoption of PSA testing underscores uncertainty and disagreement about its value for reducing prostate cancer mortality . More research is required to determine the effectiveness of screening for prostate cancer BACKGROUND Few studies have reported on late declines and long-term health-related quality of life ( HRQOL ) after prostate cancer ( PCa ) treatment . OBJECTIVE We assessed long-term HRQOL following various treatments for localized PCa . DESIGN , SETTING , AND PARTICIPANTS This cohort study of HRQOL up to 10 yr after treatment used a prospect ively accrued , nationwide PCa registry that collects longitudinal patient-reported HRQOL . INTERVENTION Various primary treatments for localized PCa . OUTCOME MEASUREMENTS AND STATISTICAL ANALYSIS The Medical Outcomes Studies 36-item Short Form and the University of California , Los Angeles , Prostate Cancer Index characterized physical function , mental health , and sexual , urinary , and bowel function and bother . Repeated measures mixed-model analysis assessed change in HRQOL by treatment over time , and logistic regression was used to measure the likelihood of a clinical ly significant decline in HRQOL . RESULTS AND LIMITATIONS Among 3294 men , 1139 ( 34 % ) underwent nerve-sparing radical prostatectomy ( NSRP ) , 860 ( 26 % ) underwent non-NSRP , 684 ( 21 % ) underwent brachytherapy , 386 ( 12 % ) underwent external beam radiotherapy , 161 ( 5 % ) underwent primary and rogen deprivation therapy , and 64 ( 2 % ) pursued watchful waiting/active surveillance . Median follow-up was 74 mo ( interquartile range : 50 - 102 ) . Most treatments result ed in early declines in HRQOL , with some recovery over the next 1 - 2 yr and a plateau in scores thereafter . Surgery had the largest impact on sexual function and bother and on urinary function , radiation had the strongest effect on bowel function , and and rogen deprivation therapy had the strongest effect on physical function . The main limitation was attrition among the cohort . CONCLUSIONS Although most men experience initial declines in HRQOL in the first 2 yr after treatment , there is little change from 3 to 10 yr and most differences between treatments attenuated over time . PATIENT SUMMARY Various treatments for prostate cancer result in a distinct constellation of adverse effects on health-related quality of life , which may have a long-term impact . These findings are helpful regarding shared decision making over choice of primary treatment BACKGROUND Using observational data to assess the relative effectiveness of alternative cancer treatments is limited by patient selection into treatment , which often biases interpretation of outcomes . We evaluated methods for addressing confounding in treatment and survival of patients with early-stage prostate cancer in observational data and compared findings with those from a benchmark r and omized clinical trial . METHODS We selected 14 302 early-stage prostate cancer patients who were aged 66 - 74 years and had been treated with radical prostatectomy or conservative management from linked Surveillance , Epidemiology , and End Results -Medicare data from January 1 , 1995 , through December 31 , 2003 . Eligibility criteria were similar to those from a clinical trial used to benchmark our analyses . Survival was measured through December 31 , 2007 , by use of Cox proportional ha 
    Output:
    
In the subgroup analysis according to the age and follow-up time , the results favored the RP and there was no specific factor affecting the outcomes .
CONCLUSIONS RP offers a better survival rate  than CT in patients with localized prostate cancer .