A common approach to care for men with low-risk localized prostate cancer (PC) is active surveillance (AS), aimed at reducing overtreatment and related complications. This study examined present data, selection criteria, and results related to AS in low- and intermediate-risk populations with particular focus on recent recommendations. These recent recommendations indicate AS as the optimal standard management method for males with low-risk PC. The main benefit of AS is the avoidance of aggressive therapies and maintaining quality of life without compromising cancer-specific survival.
Long-term statistics indicate that males on AS face a low risk of prostate cancer-specific death and metastases. The long-term findings suggest that AS is suitable for individuals with low-risk disease and does not pose significant oncological risks. However, 20% to 50% of males in recent studies required active therapy within the first five to ten years of structured AS programs. The European Association of Urology (EAU) guideline group initiated a systematic effort to standardize AS and evaluate current procedures, given the diverse selection criteria and the scarcity of prospective randomized research.
For men with intermediate-risk PC, the appropriateness of AS remains uncertain due to the higher likelihood of disease progression compared with low-risk patients. The inclusion of these patients in AS programs is justified by similar findings in certain studies for cumulative mortality and biochemical recurrence between ISUP grade groups (GG) 1 and 2 PC. Approximately 25% men were managed with active monitoring as a treatment option in the current 15-year analysis of the PROTECT trial. Still, their outcomes in terms of cancer-specific survival and metastasis-free survival were comparable.
Exclusion from AS is typically warranted in cases with adverse pathological features, such as intraductal carcinoma, cribriform patterns, or extensive Gleason pattern 4 involvement, even within ISUP GG2 disease. Frequent imaging, digital rectal exams, and repeat biopsies are considered common monitoring procedures for patients on AS. In favourable intermediate-risk cases, the frequency and level of surveillance were modified according to individual risk factors and the early features of the tumor.
The AS disqualification rate decreased from 59% to 20% during a 4-year follow-up period with MRI-guided biopsy and upfront magnetic resonance imaging (MRI). The re-biopsy identifies a greater tumor grade in 27% of patients, while TB or SB shows 17% to 20% of patients. The combined technique detects a high tumor grade at 35% as compared to 24% for the separate methods. Prostate Imaging-Quality (PI-QUAL) ratings were used to provide information on MRI quality and reporting.
Each lesion is also evaluated with the Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) score, based on overall and worst lesion findings. MRI is a crucial component of both the follow-up and AS program participation. Continuous refinement of selection criteria is needed, supported by studies on reclassification and disqualification trends, as well as patient-centered outcomes.
Future investigation should focus on integrating long-term data, genetic testing, and the prognostic significance of the Gleason pattern 4 percentage. This study highlighted that the core query is how clinical characteristics relate to patient-centered outcomes in MRI.
References: Lakes J, Al-Monajjed R, Busshoff I, et al. Modern active surveillance in low- and intermediate-risk prostate cancer without re-biopsy. Prostate Cancer Prostatic Dis. 2025. doi:10.1038/s41391-025-01010-6
