I'm just trying to make sense of the new ProtecT paper from the UK . The NY Times made it a front page story this morning. 
"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 randomization to active monitoring (545 men), surgery (553), or radiotherapy (545)." 
Seems odd that almost 62% of the 2,664 men were OK with the idea of a computer allocation to one of the three arms.
"... about three quarters had a Gleason score of 6; the rest had higher Gleason scores." 
So, two-thirds of the three-quarters who were GS=6 received treatment.
Put another way, one-half of the men received treatment, in spite of being GS=6.
& one-twelfth of the men were assigned to active monitoring in spite of GS=7-10.
Three-quarters of each treatment arm were GS=6, & this can only serve to make the statistics look way better than they actually are.
One-quarter of the men in the active monitoring arm were GS=7-10, & this would make the active monitoring statistics took worse.
"Metastases developed in more men in the active-monitoring group (33 men ...) than in the surgery group (13 men ...) or the radiotherapy group (16 men ...)"
"Higher rates of disease progression were seen in the active-monitoring group (112 men ...) than in the surgery group (46 men ...) or the radiotherapy group (46 men ...)"
So what's the message? That one should weigh the morbidity of treatment against double the risk of metastases?
It would be more useful to newly diagnosed men, to have these statistics reported by Gleason score.
"Of the 17 total prostate cancer–specific deaths, some were in men with low-risk disease, and that is troublesome, Dr Hamdy noted. "We cannot describe lethal disease well at diagnosis. We need new markers to tell us that," he said." 
By "low-risk", he presumably meant GS=6. Well, more than 25% of GS=6 men in active monitoring will progress. Active monitoring shouldn't mean waiting for mets to appear - which is what seems to have happened for 33 men. The 4-K test or something similar should have been part of the monitoring.
"An important aspect of this study design is outdated, said Stacy Loeb, MD, a urologist at New York University's Langone Medical Center, who was not involved with the study.
"Overall, the protocol of active monitoring used in ProtecT is different from that used in contemporary active surveillance programs," she said.
"In the ProtecT study, prostate biopsies were not part of regular scheduled monitoring but could be used as part of the clinical assessment of disease progression, she said.
"Dr Loeb pointed out that this differs from modern active surveillance programs, which include serial PSA testing and digital rectal examination, as well as serial prostate biopsies to check for increases in the grade or volume of the cancer.
"She also noted that in the Johns Hopkins active surveillance program, patients with very-low-risk and low-risk prostate cancer are monitored with PSA testing and prostate exams every 6 months, as well as yearly prostate biopsies.
"Dr Loeb pointed out that since the inception of this program in 1995, approximately 1300 patients have been enrolled and only 2 have died of prostate cancer. The 15-year prostate cancer–specific survival rate was 99.9% and metastasis-free survival rate was 99.4%.
""This suggests a very low risk of developing incurable disease for low-risk patients who are monitored closely," she said. "
"Dr Loeb also pointed out that other tests, such as biomarkers and MRI, are being integrated into active surveillance, which were not available when ProtecT started."
Another ProtecT paper has just appeared : "Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer."
"In terms of sexual function, 67% of the study population reported erections firm enough for intercourse, but at 6 months, this fell to 52% of the monitoring group, 22% of the radiotherapy group, and 12% of the prostatectomy group." 
"Radiation therapy had the most negative effect on bowel function at 6 months compared with the other two groups, and some bowel symptoms developed over time." 
""After 6 years, about 1 out of 5 men still needed to use pads for urinary incontinence," Dr Donovan said about the surgery group. "Some men recover, but some have longer and more lasting effects," she added. At 6 years, this 17% compared unfavorably with the 8% of the active monitoring group who needed pads and 4% of the radiation therapy group."