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Evidence on long-term outcomes after a negative biopsy, particularly prostate cancer mortality, remains limited, and optimal follow-up strategies are unclear. This nationwide population-based study assessed whether prostate-specific antigen (PSA) decline or stability during 5-a reductase inhibitor (5-ARI) therapy after a negative biopsy identifies men at very low risk of prostate cancer and prostate cancer death. Using Prostate Cancer data Base Sweden (PCBaSe Xtend), we identified men with longitudinal PSA and biopsy data who had at least one negative prostate biopsy between 2007 and 2018 and who initiated 5-ARI therapy with defined exposure and adherence criteria. PSA change during the first 2 yr of treatment was evaluated using PSA velocity and classified as stable or increasing. Follow-up started 2 yr after treatment initiation. Among 1248 men, 901 had stable PSA and 347 had increasing PSA. After 10 yr, the cumulative incidence proportion of prostate cancer was 8.3% (95% confidence interval [CI] = 6.0-12%) in men with stable PSA and 18% (95% CI = 13-24%) in men with increasing PSA; most cancers in men with stable PSA were low grade. Prostate cancer mortality was very low among men with stable PSA (standardized mortality ratio [SMR] = 0.19; 95% CI = 0.04-0.56) and higher in men with increasing PSA (SMR = 1.20; 95% CI = 0.52-2.37. Stable PSA during 5-ARI therapy after a negative biopsy was associated with very low prostate cancer mortality; whether this should influence PSA surveillance intensity requires further study.

(c) 2026 The Author(s).

Published by Elsevier B.V. on behalf of European Association of Urology. This is an open access article under the CC BY-NC-ND license (http://creative

Background and purpose: We aimed to describe temporal changes in diagnostic work-up, treatment, and prostate cancer (PCa) mortality in locally advanced PCa in 2016–2024 in Sweden.

Patient/material and methods: Men registered in the National Prostate Cancer Register of Sweden in 2016–2024 with locally advanced PCa; clinical T stage 3–4, no distant metastases, and prostate-specific antigen < 100 ng/ml were included. We computed the proportion of use of prostate magnetic resonance imaging (MRI) before biopsy, radical prostatectomy, radical radiotherapy, androgen deprivation therapy, and abiraterone, and described the trend in PCa mortality across three calendar periods.

Results: During the 9-year study period 7,484 men with locally advanced PCa were identified. Use of MRI before biopsy increased from 3% in 2016 to 73% in 2024. Concomitantly, radical treatment increased from 35% to 48%, entirely due to increased use of radiotherapy. Abiraterone was not used before 2022 but 31% received this treatment in 2024. The 3-year PCa mortality decreased from 8% (95% confidence interval [CI]: 7–9) in 2016–2018 to 6% (95% CI: 4–8) in 2022–2024.

Interpretation: In this nationwide, population-based study of men with locally advanced PCa, the use of MRI before biopsy, radical radiotherapy, and treatment with abiraterone increased over time. These changes coincided with a modest decrease in 3-year PCa mortality.

Objective

To describe the risk of urinary tract events after radical radiotherapy (RT) according to pre-RT (IPSS) overall and within subgroups of prostate volume, type of RT, and use of neoadjuvant androgen-deprivation therapy (ADT), as men who undergo RT for prostate cancer have a risk of urinary tract events.

Patients and Methods

Men in the National Prostate Cancer Register of Sweden who underwent RT between 2018 and 2023 for whom IPSS was registered at diagnosis were included. The IPSS was stratified as: low, 0–7; moderate, 8–19; and severe, 20–35 points. Urinary tract events were defined as lower urinary tract symptoms, infections, and urological procedures after treatment and assessed based on International Classification of Diseases and Related Health Problems, 10th Revision codes and procedures in The Patient Register. Competing risk of cumulative incidence proportion of urinary tract events at 3 year after RT was computed according to the IPSS, prostate volume, type of RT, and use of neoadjuvant ADT.

Results

Of the 4436 men included, 43% had mild, 44% moderate, and 13% severe pre-RT IPSS. Incidence of urinary tract events after RT was 19% at 3 years for men with mild IPSS, 28% for moderate IPSS, and 39% for severe IPSS. The association between IPSS and urinary tract events was observed within subgroups based on prostate volume, type of RT, and use of neoadjuvant ADT. A 5-unit increase in IPSS carried a 20% increased risk of having a urinary tract event within 3 years.

Conclusion

A higher pre-RT IPSS is an indicator of increased risk of urinary tract events after RT – both overall and within subgroups of prostate volume, type of RT, and use of neoadjuvant ADT.

Background It is unknown if a period of active surveillance before prostatectomy for prostate cancer (PCa) worsens functional outcomes. The aim of this study was to compare functional outcomes after primary vs delayed robot-assisted radical prostatectomy.Methods We included men registered in the National Prostate Cancer Register of Sweden with low and favorable intermediate-risk PCa who underwent robot-assisted prostatectomy in 2018-2020 and had filled a questionnaire on patient-reported outcome measures. Multivariable logistic regression analysis was used to compare the functional outcomes of primary and delayed prostatectomy.Results 2571 men underwent primary, and 921 men underwent delayed prostatectomy. Delayed prostatectomy was not associated with reduced overall quality of life (adjusted Odds Ratio [OR] 1.04; 95% confidence interval [CI] 0.71-1.55) or erectile dysfunction (adjusted OR 0.90, 95% CI 0.69-1.22). Urinary incontinence was slightly more common after delayed prostatectomy (15% vs 11%; adjusted OR 1.38, 95% CI 0.91-2.01). There were weak associations between time to prostatectomy and urinary symptoms and bother, with a 3% annual increase in the risk for urinary incontinence (adjusted OR 1.03; 95% CI 0.94-1.13).Conclusion These results suggest that a period on active surveillance before robot-assisted radical prostatectomy has little detrimental effect on functional outcomes. Since only around half of men on active surveillance will transit to prostatectomy, these outcomes represent a worst-case scenario for men who start active surveillance. These results support the use of active surveillance for men with low-risk and favorable intermediate-risk PCa.

Background: Swedish national guidelines provide evidence-based recommendations for standard of care; however, little is known about adherence to them. The aim of this study was to assess adherence to management guidelines for prostate cancer (PCa).

Materials and methods: Data in the National Prostate Cancer Register (NPCR), that includes 98% of all incident PCa cases in Sweden, were used to analyse adherence to national PCa guidelines for men diagnosed between 2010 and 2023. A selection of quality indicators displayed on the public web page of NPCR were assessed.

Results: Active surveillance in men with low-risk PCa and an estimated life expectancy >10 years increased from 44% in 2010 to 88% in 2023. Radical treatment for men with localised high-risk PCa and life expectancy >10 years increased from 60% in 2010 to 86% in 2023 and for men with locally advanced PCa and life expectancy >5 years from 37% in 2010 to 64% in 2023. The proportion of radical prostatectomies for low- or intermediate-risk PCa performed with nerve-sparing technique increased from 61% in 2015 to 87% in 2023. Use of adjuvant androgen deprivation therapy after radiotherapy for men with high-risk or locally advanced PCa increased five-fold from 14% in 2010 to 73% in 2022.

Conclusion: Adherence to recommendations in national guidelines improved in Sweden between 2010 and 2023. Public, open reporting of NPCR data on adherence to guidelines down to department level is likely to have contributed to these improvements.

Background: Data on long-term outcomes for men with prostate cancer treated according to current guidelines are limited. We aimed to estimate the long-term risk of death from prostate cancer and other causes in men with nonmetastatic prostate cancer who received primary treatment according to current guidelines.

Methods: Men with nonmetastatic prostate cancer registered in the National Prostate Cancer Register of Sweden from 2000 to 2020, who received primary treatment according to NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) for Prostate Cancer, Version 4.2023, were included and followed until December 31, 2022. The risk of death from prostate cancer and other causes up to 30 years was estimated according to risk category and life expectancy using a state transition simulation model.

Results: A total of 62,839 men received primary treatment according to the NCCN Guidelines. The simulated 15-year prostate cancer mortality per risk category ranged from 5.5% (95% CI, 4.8%-6.2%) in men with low-risk cancer to 22% (95% CI, 21%-24%) in men with very high-risk cancer. Simulated 30-year prostate cancer mortality ranged from 12% (95% CI, 10%-14%) in men with low-risk cancer to 30% (95% CI, 29%-32%) in men with very high-risk cancer, whereas death from other causes ranged from 77% (95% CI, 74%-80%) to 63% (95% CI, 59%-67%), respectively.

Conclusions: Men with nonmetastatic prostate cancer who received primary treatment according to current guidelines were up to 6 times more likely to die of other causes than from their cancer. These estimates provide realistic but high expectations of the outcomes of modern treatment and can serve as benchmarks for clinical outcome reporting.