Active Surveillance for Intermediate-Risk Prostate Cancer

Yes, But for Whom?

Maya R. Overland; Samuel L. Washington III; Peter R. Carroll; Matthew R. Cooperberg; Annika Herlemann


Curr Opin Urol. 2019;29(6):605-611. 

In This Article

Abstract and Introduction


Purpose of review: Active surveillance is becoming more widely accepted as an initial management option for carefully selected men with favorable intermediate-risk prostate cancer (PCa). As prospective active surveillance cohorts mature sufficiently to begin evaluating longer-term outcomes, consensus on more precise evidence-based guidelines is needed to identify the patient cohorts who may be safely managed with active surveillance and what the ideal surveillance protocol entails.

Recent findings: Long-term outcomes updates have suggested a trend toward worse 15-year survival outcomes for intermediate-risk patients on active surveillance compared with definitive treatment, but 'intermediate-risk' is a broad category and there is a subset of favorable intermediate-risk patients for whom survival outcomes remain equivalent. Promising updates to current risk stratification include consideration of genomic classifiers, advanced imaging and more nuanced interpretation of biopsy results.

Summary: Despite widespread acknowledgement of the pitfalls of overtreatment in clinically localized PCa, utilization of active surveillance in the intermediate-risk population remains marginal, in part due to the absence of easily interpretable consensus recommendations. As more long-term outcomes data become available for this subgroup, the field is now poised to refine the definition of favorable intermediate-risk patients for whom active surveillance is a safe, evidence-based first-line management option.


Active surveillance has become widely adopted as the preferred management strategy for most men with low-risk prostate cancer (PCa), to avoid overtreatment of clinically indolent disease and to safely delay definitive treatment until evidence of progression is identified. As the field gains experience and comfort with active surveillance for carefully selected men with intermediate-risk disease, risk stratification strategies must be further refined to identify the subgroups of men within the intermediate-risk group for whom active surveillance remains a reasonable management option, in order to establish evidence-based protocols. A major limitation of current intermediate-risk stratification protocols is the over-reliance on histologic morphology and, while there is evidence demonstrating that volume of higher grade disease is a predictor of disease progression, this represents a phenotypic representation overlying significant genetic heterogeneity with variable aggressive potential, for which there can be no one-size-fits-all recommendation. Several recent reviews have thoroughly examined this issue and the current state of the field.[1–4] Our goal in this review is to provide an updated summary of the current evidence, with an emphasis on recent scientific developments including newly available long-term survival outcomes from prospective active surveillance cohorts and how these findings may be interpreted and integrated into clinical practice.