Prostate cancer ranks as the most frequently diagnosed cancer in men globally and is the second leading cause of cancer-related death (1). Nevertheless, the prognosis of localized disease remains favorable and potentially curable. Prostatectomy and definitive radiation represent the mainstay treatment options for this disease, and many reports in the literature have shed light on the advantages and complications of each approach, but outcomes are still controversial, given the heterogeneity of surgical and radiation techniques, in addition to patients and disease characteristics (2–4).

According to the American Cancer Society (ACS), Prostate-Specific Antigen (PSA) testing for men at average risk should begin at age 50 through informed and shared decision-making (5). Widespread PSA testing in several developed countries has led to a reduction in mortality, largely by increasing the detection of early-stage localized prostate cancers (6, 7). Nevertheless, a study from Jordan revealed that only 13% of older men adhered to prostate cancer screening guidelines over the past decade, and it seems that the absence of a national screening program remains a significant barrier to early detection (8, 9).

Treatment of localized prostate cancer typically ranges from active surveillance to active interventions such as surgery, radiotherapy, and androgen deprivation therapy (ADT). The treatment option is usually dictated by a multidisciplinary panel according to disease stage, risk group, performance status, and genetics, in addition to personal preferences and other factors (10). Recent years have witnessed significant advancements in treatment strategies, including the adoption of robotic surgery and the introduction of state-of-the-art radiation techniques. It is yet to be disclosed whether such a transition to more advanced treatments has influenced the oncologic outcomes in localized prostate cancer patients in a resource-limited country like Jordan.

Multiple studies in the literature have compared the oncologic outcomes of surgery and radiotherapy, and almost all of these series were retrospective in nature. To the best of our knowledge, this is the first series from the Middle East and North Africa (MENA) region comparing both modalities in localized prostate cancer. Investigating this population is particularly important given the absence of structured screening programs, the tendency for patients to present with more advanced disease, and the potential influence of a distinct genomic landscape (11–13). Moreover, it represents real-world evidence on the current practices and outcomes when compared with results from high-income countries.

This study aims to compare radical prostatectomy and definitive radiotherapy for patients with localized prostate cancer managed at a tertiary cancer center in Jordan, reporting patients and disease characteristics as well as survival outcomes.

This study provides a comprehensive overview of the disease characteristics and treatment outcomes of localized prostate cancer in Jordan over 14 years. This relatively large cohort of 317 patients offers a comprehensive comparison of surgery and radiotherapy for localized prostate cancer. To the best of our knowledge, such a comparison from our region has not been previously reported. Furthermore, we captured multiple epidemiologic and disease-related findings. For instance, only 3.8% had T1 disease, highlighting the lack of comprehensive prostate cancer screening programs, which resulted in a more advanced stage at presentation 62.5%. The ACS recommended that men at average risk for prostate cancer engage in shared decision-making regarding PSA testing, starting at the age of 50 years (5). Meanwhile, the American Urological Association (AUA) and the U.S. Preventive Services Task Force (USPSTF) advised screening men aged 55 to 69 years based on an individual basis, but may be offered for men with certain risk factors between 40 and 54 years (14, 17). This is particularly crucial given Jordan’s evolving demographic profile, which exhibits an increasing proportion of older adults, making early detection efforts paramount (3, 11, 18).

The choice of the optimal treatment for localized prostate cancer is challenging, as it relies on several factors, including patient age, performance status, and disease grade and stage. Additional considerations, such as patient preference, available treatment techniques, and anticipated toxicity, also play a critical role. Therefore, treatment decisions are typically individualized under the umbrella of multidisciplinary discussion and the patient’s wishes. While multiple comparative studies have explored outcomes between surgery and radiotherapy, most available data originate from high-income countries, with a noticeable lack of comparative evidence from the Middle East and other LMIC settings. This gap is noteworthy, especially as molecular studies have demonstrated potential biological and genomic differences among prostate cancer populations in the region (19).

Given the available evidence, most comparative studies between surgery and radiotherapy have been retrospective analyses or meta-analyses. Only a limited number of clinical trials have attempted to evaluate both approaches in a randomized fashion to minimize bias. One example is the multicenter Swedish trial by Lennernäs et al. (20), which included men with T1–T3a disease and demonstrated comparable outcomes between the two modalities over a relatively short follow-up period (20). Another important study is the ProtecT randomized trial, which also demonstrated no significant difference in prostate cancer–specific mortality between active monitoring, surgery, and radiotherapy, although they observed higher rates of disease progression and metastasis in the active monitoring arm (2). Similarly, a Japanese trial by Akakura et al, concluded with both surgery and prostatectomy (21). A more recent study is the PACE-A, which investigated prostatectomy and stereotactic body radiotherapy (SBRT), however, only toxicity and quality-of-life data have been published thus far, while oncologic outcomes remain pending. Our results, therefore, provide comparative outcome data from a Middle Eastern cohort, contributing region-specific evidence to the limited global literature. Table 2 compares OS and CSS events in our study to available prospective data. Notably, the CSS in our study is lower than other studies, such as ProtecT, which includes a more favorable patient cohort; nevertheless, the death rate from prostate cancer remains relatively low across different experiences and regions from the world.

Another interesting finding was that the OS in low-risk patients was lower than in other risk groups, which might reflect the effect of competing causes of death in our population. However, the relatively small number of patients in this group might also have contributed to this observation.

With the exception of the small Japanese cohort, most patients in these prospective studies had favorable disease characteristics, primarily low- and intermediate-risk disease, which was reflected in the low number of events across these trials. In contrast, treatment of the high-risk group remains a subject of debate at the multidisciplinary level. There is high-level evidence that the addition of radiation and ADT in high-risk disease is associated with a survival benefit (23). Nevertheless, only one clinical trial tested surgery in high-risk patients, the Scandinavian SPCG-15, but the results have not yet been published (24). Despite this, surgical management continues to be broadly accepted across urology societies worldwide, as supported by population-based studies and meta-analysis reports (25). For example, Wallis et al. carried out a systematic review of 19 studies to address the lack of level 1 evidence, and found that mortality was higher with radiotherapy, acknowledging the potential bias (4). In contrast, a recent pooled analysis of two phase III trials in high-risk prostate cancer demonstrated that patients treated with radiotherapy had a lower incidence of distant metastasis (26).

A consistent finding across multiple studies is that older patients with more advanced disease are more likely to receive radiotherapy, whereas younger patients with less advanced disease are preferentially treated with surgery. This difference in baseline characteristics may partially explain the relatively higher all-cause mortality observed in radiotherapy series (27, 28). In summary, surgery and radiotherapy appear to offer comparable oncologic outcomes, particularly in early disease. Nevertheless, in high-risk disease, the outcomes are conflicting, largely due to inherent differences in clinical and disease characteristics and potential bias in patient selection.

Interestingly, we observed better BRFS in the radiotherapy group compared with surgery (90.5% vs. 59.8%), which could be related to the high percentage of positive margins (36%) in our surgical series. Although this rate exceeds those typically reported in the literature (20–27%) (29), it is likely attributable to the high incidence of extracapsular extension in our patients (46.1%), as several reports have shown that margin positivity can reach up to 44% in cases with T3 disease. Moreover, extracapsular extension was associated not only with higher rates of positive surgical margins but also with poorer biochemical control (30), which might have contributed to the inferior BRFS observed with surgery in our study, especially because we detected inferior BRFS with a positive margin compared to a negative one. Moreover, the routine use of ADT in conjunction with radiotherapy for intermediate- and high-risk patients likely contributed to improved biochemical control in this group. As previously mentioned, clinical trials have demonstrated that combined radiotherapy and long-term ADT significantly improve progression-free and overall survival in high-risk prostate cancer (31, 32).

A key observation from our analysis is that oncologic outcomes have remained stable, with slight improvements over time, despite the evolution of treatment techniques. OS was comparable across treatment eras, and CSS and BRFS showed modest gains in more recent years. These improvements might reflect advances in treatment delivery, including the introduction of IMRT and VMAT at our center. While such techniques are not expected to directly enhance oncologic outcomes, they may contribute to reduced toxicity and improved treatment tolerability (33, 34). Similarly, the adoption of laparoscopic and robotic surgery has been associated with fewer postoperative complications, but the effect on oncologic outcomes is controversial (35). Collectively, the gradual integration of more advanced treatment modalities appears to have resulted in modest improvements in disease control and survival, accompanied by better management of treatment-related complications. However, these observations warrant formal evaluation through cost-effectiveness analyses, particularly in financially constrained settings such as Jordan. In resource-limited environments, the management of localized prostate cancer should be guided by risk stratification, available expertise, and cost-effectiveness considerations, given the comparable survival outcomes observed between surgery and radiotherapy. Treatment selection should therefore depend on the availability of radiotherapy services or experienced surgeons in high-volume centers and be determined within a multidisciplinary framework, with greater centralization of care to optimize outcomes and ensure efficient use of limited resources.

While our study offers valuable insights, several limitations must be acknowledged. The retrospective design introduces a potential selection bias, particularly in treatment allocation. This was clear in the age and risk groups distribution between arms; these baseline confounders might have implications for the study results and reported outcomes. Therefore, our findings should be interpreted with caution, but these results may serve as hypothesis-generating data for future prospective randomized clinical trials or propensity score-matched analysis. Another major limitation of this study is the lack of detailed information on treatment-related toxicity, quality of life, and functional outcomes, including urinary, bowel, and sexual function. The absence of these data precludes a comprehensive comparison of the true patient-centered impact of radical prostatectomy and radiotherapy and limits their incorporation into shared decision-making for men with localized prostate cancer. Addressing this critical gap should be a priority for future prospective, multicenter research efforts in the region, with systematic collection of patient-reported outcomes to better inform treatment selection.

Despite these limitations, this study provides the first comparative evidence from the MENA region showing that both radical prostatectomy and radiotherapy can achieve excellent long-term oncologic outcomes in localized prostate cancer when delivered in a tertiary cancer center under the umbrella of multidisciplinary decision-making. Future efforts should focus on early screening and detection using novel tools such as MRI and PSMA, in addition to the integration of quality-of-life scores to capture real-world complications of each treatment modality.

This study represents the first comprehensive comparison of radical prostatectomy and radiotherapy for localized prostate cancer in Jordan and, to our knowledge, in the MENA region. Both treatment modalities demonstrated excellent long-term oncologic outcomes, with no significant differences in overall or cancer-specific survival. Radiotherapy, particularly when combined with ADT, was associated with superior biochemical control, while surgery showed higher recurrence rates, largely influenced by adverse pathological features such as positive margins and extracapsular extension. Notably, despite evolving treatment techniques, oncologic outcomes have remained stable, with modest improvements in biochemical control observed over the years. These findings emphasize the importance of delivering care within a multidisciplinary approach. The treatment of localized prostate cancer should be individualized according to clinical and disease characteristics. Future prospective multicenter collaborations across the region are needed to validate these findings, assess patient-reported outcomes, and evaluate cost-effectiveness in resource-limited settings.