When Surveillance Turns to Surgery: What a Norwegian Study of 7,600 Men Tells Us

Surveillance Before Prostatectomy Tied to Adverse Pathology

Men who had surgery after a period of active surveillance had more advanced disease in the removed prostate, but their ten-year survival was the same. The lesson is about how surveillance is done, not whether to do it.

Stephen L. Pendergast, IPCSG  |  September 2026

Bottom Line Up Front

A nationwide Norwegian registry study published September 19, 2026 in the World Journal of Urology compared 1,839 men who had their prostate removed after a period of active surveillance with 5,767 similar men who had surgery right away. The surveillance-then-surgery group had about twice the odds of "adverse pathology" (cancer that was higher grade or had grown beyond the prostate) and a roughly 50% higher adjusted chance of needing radiation or hormone therapy after surgery.¹

The reassuring part: ten-year prostate cancer survival did not differ between the two groups, and three out of four men on surveillance never went on to surgery during the study.¹ This is consistent with the 15-year ProtecT randomized trial.³

The practical message for men on surveillance: make sure your surveillance is truly active, with scheduled PSA, PSA density, MRI and repeat biopsy as your team recommends, and treat a rising PSA as a reason for a prompt re-look.

The question

Active surveillance (AS) is now the recommended starting point for most men with low-risk prostate cancer, and an accepted option for selected men with favorable intermediate-risk disease.¹² Rather than treating right away, a man is monitored, and treatment is offered if the cancer shows signs of change. The logic is simple: many of these cancers will never threaten a man's life, and surgery and radiation carry real risks to urinary, sexual and bowel function.

But a substantial share of men on surveillance eventually do have treatment. A fair question for anyone considering AS is: if I end up needing surgery later, will I be worse off than if I had had it at the start? That is exactly what the Norwegian team set out to measure.

What the Norwegian researchers did

Ingrid Hannestad and colleagues at the University of Oslo, Akershus University Hospital and the Cancer Registry of Norway used the national Norwegian Prostate Cancer Registry, which captures nearly every prostate cancer diagnosis in the country.¹ They looked at men diagnosed from 2009 through 2022 who were 40 to 79 years old, with PSA of 20 or less, Grade Group 1 or 2 (Gleason 3+3 or 3+4), clinical stage T2b or lower, and no spread at diagnosis.

Of the 8,013 men in the final surveillance group, 1,839 later had a radical prostatectomy ("deferred" surgery). The median time from diagnosis to that surgery was about 23 months, and median follow-up from diagnosis was 5.6 years. They were compared with 5,767 men with similar disease who had surgery within a year of diagnosis ("immediate" surgery).¹

Key findings: deferred vs. immediate prostatectomy (Norway, 2009–2022)

Measure	Deferred (after AS)	Immediate
Grade Group 1 at diagnosis	78%	30%
Nerve-sparing surgery	77%	83%
Pelvic lymph node dissection	33%	20%
Any adverse pathology in the removed prostate	58%	47%
Cancer outside the prostate (pT3 or higher)	36%	29%
Grade Group 3 or higher at surgery	29%	16%
Positive surgical margins	No difference
Adjusted odds of adverse pathology	About 2× higher after deferred surgery (OR 1.99)
Adjusted risk of post-surgery radiation/hormone therapy	About 1.5× higher after deferred surgery (HR 1.52)
Prostate cancer deaths	6	27
10-year prostate cancer-specific survival	No significant difference

Source: Hannestad et al., World J Urol 2026.¹ "Adjusted" means the comparison accounts for differences between the groups at the time of diagnosis.

Some details worth noticing

• The men who ended up in surgery started out with better tumors. At diagnosis, 78% of the deferred group had Grade Group 1 disease versus 30% of the immediate group. By the time of surgery, however, 18% of the deferred group had progressed to high-risk features.¹
• Waiting longer went with worse findings. Compared with surgery at six months to two years, surgery after two to five years, and especially after five or more years, was linked to higher odds of adverse pathology (roughly 2.9 times for five years or more).¹
• PSA mattered most. Among men with deferred surgery, PSA just before the operation was the only factor that predicted needing more treatment afterward. Compared with PSA under 10, a PSA of 10–20 more than doubled the odds, and a PSA over 20 raised them more than four-fold.¹
• The raw numbers look different from the adjusted ones. In plain counts, 10% of the deferred group and 13% of the immediate group got radiation or hormone therapy after surgery. It is only after accounting for how favorable the deferred group's cancers looked at diagnosis that deferral shows a higher risk. In the later years of the study, that extra risk disappeared, which the authors think may reflect modern practice of using "early salvage" radiation rather than routine radiation right after surgery.¹

Reading the numbers: why this is not a verdict against surveillance

Registry studies like this one describe associations, not cause and effect. The men who went from surveillance to surgery are, almost by definition, the men whose cancers looked like they were changing. Comparing them with everyone who had immediate surgery will tend to make the deferred group look worse. The authors themselves say the findings most likely reflect true progression during surveillance, while noting that some "upgrading" may simply be the surgeon's specimen revealing cancer that a biopsy had undersampled.¹

The registry also lacked key information: how often men were monitored, MRI results, repeat biopsies, how fast PSA was rising, why each man chose surgery, and PSA levels after surgery. There were no data on PSA recurrence or metastases, and follow-up was relatively short.^1,2 In engineering terms, we know the output of the system but not how well the sensors were working.

How this fits with other evidence

The ProtecT trial: the gold standard

The strongest evidence on "treat now or watch" comes from the UK ProtecT trial, which randomly assigned 1,643 men with PSA-detected localized prostate cancer to active monitoring, surgery or radiation. After a median 15 years, prostate cancer deaths were low and statistically similar: 3.1% with monitoring, 2.2% with surgery and 2.9% with radiation.^3,4 However, men in the monitoring arm had about twice the rate of metastases (9.4% versus 4.7% and 5.0%) and more often needed long-term hormone therapy (12.7% versus 7.2% and 7.7%).⁴ Lead investigator Freddie Hamdy summarized that a quick treatment decision is not necessary and "could cause harm."⁵

The Norwegian findings echo this pattern: more disease progression and more downstream treatment with a watch-first strategy, without a measurable survival penalty over the time studied. It is worth remembering that ProtecT's monitoring arm relied mainly on PSA testing and predates routine MRI, so today's surveillance should, in principle, catch progression earlier.

Other studies of delayed surgery

• Sweden (nationwide, 2016): Men with delayed prostatectomy were nearly twice as likely to receive salvage radiation as men treated immediately.^1,6
• Göteborg, Sweden (2018): In a screening-trial surveillance cohort, 39% of men who later had surgery showed at least one adverse feature, yet 10-year PSA relapse-free survival was 79.5% and there were no prostate cancer deaths after deferred surgery.^1,7
• UCSF (2019): Among 1,916 men on surveillance, 23.4% eventually had surgery, at a median of 27 months. Men who started with Grade Group 2 disease in two or more biopsy cores had a higher risk of PSA recurrence than men with Grade Group 1, while those with only one Grade Group 2 core did not.⁸
• UCSF (2024): In roughly 1,200 men with Grade Group 2 cancer, those who had surgery after being upgraded on surveillance did not have significantly more recurrence than those operated on right away, after accounting for other factors, even when surgery came more than 12 months after the upgrade.^9,10

What about side effects?

A common worry is that waiting will make surgery harder on continence and potency. A 2025 Swedish national study of 3,492 men who had robot-assisted prostatectomy found that a prior period of surveillance did not reduce overall quality of life or worsen erectile function. Urinary leakage was slightly more common after delayed surgery (15% versus 11%), but that difference was not statistically significant.¹¹ The Norwegian study did find somewhat fewer nerve-sparing operations after deferral (77% vs. 83%), which is consistent with more advanced disease at surgery.¹

Recent research on making surveillance smarter

If the key is catching progression promptly, the question becomes: who needs closer watching? Several 2025–2026 reports address this, particularly for Grade Group 2 (Gleason 3+4) cancer, where surveillance is growing but less settled.

• UCSF, ASCO GU 2026: Among 319 men with confirmed Grade Group 2 cancer on surveillance, about two-thirds had active treatment by 10 years, but metastasis was uncommon (3.4% at 10 years) and there were no prostate cancer deaths. A PSA density of 0.15 or higher and a suspicious MRI (PI-RADS 4–5) predicted progression; genomic testing did not add significantly in this series.¹³
• MRI-era Grade Group 2 surgery study (The Prostate, 2026): Having more than 25% Gleason pattern 4 on biopsy, and higher PSA density, were the main factors tied to adverse findings and recurrence; PI-RADS score and biopsy cancer volume were not.¹⁴
• European multicenter cohort (2025): In 139 MRI-selected men with Grade Group 2 cancer on surveillance, the estimated 3-year metastasis-free survival was 98.1%, with two metastases and no prostate cancer deaths.¹⁵
• AUA 2026 annual meeting: A review of Grade Group 2 management noted that the Decipher genomic test appears most useful for flagging clinically meaningful progression (to Grade Group 3 or unfavorable histology) rather than any upgrade at all.¹⁶

These findings do not all agree on which tool matters most, which is itself a useful lesson: no single test tells the whole story. PSA density, the amount of pattern 4 on biopsy, MRI and, in some cases, genomic testing are pieces of a risk picture your doctors assemble together.

What the guidelines say

The AUA/ASTRO guideline on clinically localized prostate cancer recommends active surveillance as the preferred management for low-risk disease, and says clinicians should discuss surveillance, radiation and prostatectomy with men who have favorable intermediate-risk disease.¹² The Norwegian study does not change those recommendations. Its authors conclude instead that surveillance should be risk-adapted, with closer monitoring for men at higher risk of progression and prompt urologic evaluation when PSA is rising, even if a biopsy has not yet shown a change in grade.¹

What this means for you

If you are on active surveillance, or considering it, these are reasonable questions to bring to your urologist:

1. What is my surveillance schedule for PSA, MRI and repeat biopsy, and is it tailored to my risk?
2. What is my PSA density, and how is my PSA trending over time?
3. If I have Grade Group 2 cancer, how much pattern 4 is in my biopsy, and are cribriform or intraductal features present?
4. Would a genomic test such as Decipher change your recommendation for me?
5. What specific change (in PSA, MRI or biopsy) would lead you to recommend treatment?
6. If my PSA rises between scheduled visits, how quickly will I be re-evaluated?

The core message is balanced. Surveillance continues to spare most men from treatment they do not need, and the survival data remain reassuring. But surveillance is an active process. Men who drift for years without scheduled imaging and biopsies, or whose rising PSA goes unexamined, may give up some of the options they would otherwise have had.

Sources

1. Hannestad I, Myklebust TÅ, Fosså SD, Muller S, Aas K. Does active surveillance prior to radical prostatectomy increase the risk of adverse pathological findings or postoperative prostate cancer treatment? World J Urol. 2026;44:679. doi:10.1007/s00345-026-06617-5. https://link.springer.com/article/10.1007/s00345-026-06617-5
2. Active surveillance before radical prostatectomy tied to adverse pathology. Medscape. September 25, 2026. https://www.medscape.com/viewarticle/active-surveillance-before-radical-prostatectomy-tied-2026a1000zw7
3. Hamdy FC, Donovan JL, Lane JA, et al. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med. 2023;388(17):1547–1558. doi:10.1056/NEJMoa2214122. https://www.nejm.org/doi/full/10.1056/NEJMoa2214122
4. Active monitoring, surgery, or radiotherapy for localized prostate cancer: 15-year outcomes in the UK ProtecT trial. The ASCO Post. March 2023. https://ascopost.com/news/march-2023/active-monitoring-surgery-or-radiotherapy-for-localized-prostate-cancer-15-year-outcomes-in-the-uk-protect-trial/
5. Delaying treatment for patients with localized prostate cancer may not increase mortality risk, ProtecT trial shows. The ASCO Post. March 2023. https://ascopost.com/news/march-2023/delaying-treatment-for-patients-with-localized-prostate-cancer-may-not-increase-mortality-risk-protect-trial-shows
6. Loeb S, Folkvaljon Y, Robinson D, et al. Immediate versus delayed prostatectomy: nationwide population-based study. Scand J Urol. 2016;50(4):246–254. doi:10.3109/21681805.2016.1166153. https://doi.org/10.3109/21681805.2016.1166153
7. Godtman RA, Schafferer M, Pihl CG, Stranne J, Hugosson J. Long-term outcomes after deferred radical prostatectomy in men initially treated with active surveillance. J Urol. 2018;200(4):779–785. doi:10.1016/j.juro.2018.04.078. https://doi.org/10.1016/j.juro.2018.04.078
8. Balakrishnan AS, Cowan JE, Cooperberg MR, et al. Evaluating the safety of active surveillance: outcomes of deferred radical prostatectomy after an initial period of surveillance. J Urol. 2019;202(3):506–510. doi:10.1097/JU.0000000000000247. https://doi.org/10.1097/JU.0000000000000247
9. Shee K, Cowan JE, Washington SL, et al. The impact of delayed radical prostatectomy on recurrence outcomes after initial active surveillance: results from a large institutional cohort. Eur Urol Oncol. 2024;7(4):838–843. doi:10.1016/j.euo.2023.11.011. https://doi.org/10.1016/j.euo.2023.11.011
10. Delayed prostatectomy following active surveillance does not affect recurrence [interview with Kevin Shee, MD, PhD]. Urology Times. https://urologytimes.com/view/delayed-prostatectomy-following-active-surveillance-does-not-affect-recurrence
11. Corsini C, Scilipoti P, Orrason AW, Gedeborg R, Westerberg M, Stattin P. Functional outcomes after primary vs delayed robot-assisted radical prostatectomy following active surveillance. JNCI Cancer Spectr. 2025;9(2):pkaf020. doi:10.1093/jncics/pkaf020. https://pmc.ncbi.nlm.nih.gov/articles/PMC11884805/
12. Eastham JA, Auffenberg GB, Barocas DA, et al. Clinically localized prostate cancer: AUA/ASTRO guideline, parts I–III. J Urol. 2022;208(1):10–33. American Urological Association. https://www.auanet.org/guidelines-and-quality/guidelines/clinically-localized-prostate-cancer
13. Shee K, et al. The nature of progression on active surveillance for grade group 2 prostate cancer [abstract 330]. J Clin Oncol. 2026;44(7_suppl):330. doi:10.1200/JCO.2026.44.7_suppl.330. https://ascopubs.org/doi/10.1200/JCO.2026.44.7_suppl.330
14. Li, et al. Outcomes of patients with favorable intermediate risk Gleason Grade Group 2 prostate cancer undergoing radical prostatectomy in the MRI era: refining active surveillance selection criteria. Prostate. 2026;86(12):1251–1257. doi:10.1002/pros.70206. https://pubmed.ncbi.nlm.nih.gov/42257571/
15. Baboudjian M, Leni R, Oderda M, et al. Active surveillance of grade group 2 prostate cancer: oncological outcomes from a contemporary European cohort. Eur Urol Oncol. 2025. https://pubmed.ncbi.nlm.nih.gov/39965999/
16. AUA 2026: Localized treatment – the daily triage of Grade Group 2 prostate cancer. UroToday. May 18, 2026. https://www.urotoday.com/conference-highlights/aua-2026/aua-2026-prostate-cancer/169170-aua-2026-localized-treatment-the-daily-triage-of-grade-group-2-prostate-cancer.html

This article is for education and discussion within the Informed Prostate Cancer Support Group. It is not medical advice. Decisions about surveillance or treatment should be made with your own medical team, who know the details of your case.