Active Surveillance, Focal Therapy and Surgery in Prostate Cancer: Which Path for Which Patient?

Not every man diagnosed with prostate cancer needs immediate surgery or radiation therapy. Today the world's two major guidelines, those of the European Association of Urology (EAU, 2026 update) and the US National Comprehensive Cancer Network (NCCN, 2026 version 5), agree on the same principle: prostate cancer is managed along three different paths according to the “risk” of the disease and the patient's “remaining life expectancy”. The choice between active surveillance, focal therapy and surgery is made by reading these two pieces of information together.

Not Every Prostate Cancer Is the Same Disease

1. Active surveillance: Cancer is present but slow-growing and not dangerous; it is followed with regular check-ups, and treatment is started only when needed.
2. Focal therapy: Instead of the whole prostate, only the area containing the tumour is destroyed; it is still a method used in selected patients and preferably within a research setting.
3. Surgery (radical treatment): The entire prostate is removed surgically or eliminated with radiation therapy; this is needed when the disease has the potential to threaten life.

The aim of this article is to explain, in plain language, which patient is directed to which path and why, the real results of the major studies these decisions are based on, and the points you should know as a patient when talking to your doctor. At the time of diagnosis the most feared question is “will my cancer kill me?”; it must be said from the very start that the data we have today give a highly reassuring answer to this question for many patients.

How Is the Decision Made: Four Criteria That Determine Risk

The treatment decision is not based on a single number but on reading four pieces of information together. These four pieces of information place the patient in a risk group, and the risk group largely determines whether active surveillance, focal therapy or surgery is appropriate.

We explain what the grade in the biopsy report means in our article what is the Gleason score, and how an MRI-guided targeted biopsy is performed in our article on MRI-TRUS fusion prostate biopsy.

When this information is combined, the disease is divided into three main risk groups. The intermediate-risk group is itself split into “favourable” and “unfavourable”; the EAU 2026 guideline has formalised this distinction and introduced a new five-tier classification.

Why is life expectancy decisive?

Prostate cancer progresses slowly; the survival benefit of a treatment often becomes apparent only after ten years. For this reason the EAU defines a life expectancy of more than ten years as a prerequisite for benefiting from local treatment. Age alone is not the measure: in patients over 70, overall health is assessed with geriatric assessment tools such as the G8. In patients with a life expectancy below ten years and no symptoms, “watchful waiting” is preferred to avoid the side effects of treatment; unlike active surveillance, it aims not to cure but to control symptoms.

Additional decision tools

When the decision remains uncertain, two supporting tools can come into play. Genomic tests such as Decipher, Prolaris and Oncotype estimate the risk of progression from gene activity in the tumour tissue; according to UCSF data presented at the 2026 AUA congress, a high Decipher score roughly doubles the risk of upgrading to ISUP 3 in patients under surveillance. The EAU considers these tests “promising” but has not yet adopted them for routine use. PSMA PET imaging, on the other hand, is the most sensitive method for showing whether the disease has spread in the body in high-risk patients.

Active Surveillance: When Is “Waiting” the Right Treatment?

Active surveillance does not mean leaving the cancer untreated; it means following the cancer closely with a regular, predefined programme without losing the opportunity for cure. The aim is to avoid the side effects of surgery or radiation, such as urinary incontinence and loss of sexual function, for a cancer that would never cause a problem. The EAU 2026 guideline states this with the strongest level of recommendation: active surveillance should be offered as the standard approach to all low-risk patients and to selected favourable intermediate-risk patients. NCCN 2026 likewise defines active surveillance as the single “strongly recommended” preferred option for low risk. You can also find the basic principles of the method in our article on active surveillance in prostate cancer.

Who are the candidates?

• ISUP 1 (Gleason 3+3) cancer, PSA below 10, tumour confined to the prostate on examination and MRI: for these patients active surveillance is the first option.
• ISUP 2 (Gleason 3+4), but with a limited grade 4 pattern (below 10%), PSA below 10, low PSA density and few positive biopsy cores: surveillance can also be considered in these patients. PRIAS, the world's largest surveillance programme based in the Netherlands, accepts ISUP 2 patients with PSA up to 20 and PSA density up to 0.25 if there is no cribriform or intraductal pattern.
• Cribriform or intraductal pattern, grade ISUP 3 or higher, extension beyond the capsule: if any of these findings is present, active surveillance is not recommended.

How is follow-up done?

The minimum programme recommended by the EAU is: PSA at least every six months, a digital rectal examination once a year, MRI when needed and a repeat biopsy every two to three years, until life expectancy falls below ten years. If the diagnosis was made with an MRI-guided targeted biopsy, the “confirmatory biopsy” in the first year can be omitted. In low-risk patients whose MRI is unchanged and whose PSA density stays below 0.15, the repeat biopsy can also be omitted. This means that surveillance is not equally intensive for every patient and becomes progressively less frequent in low-risk patients.

When is treatment started?

The common principle of the guidelines is that the decision should be based not on a PSA rise or a change on MRI, but on the result of a repeat biopsy. PSA doubling in less than three years or progression on MRI is a reason for a biopsy, not a reason for treatment. Upgrading to ISUP 3, the appearance of a cribriform or intraductal pattern, or a marked increase in tumour volume on biopsy are the strongest reasons to switch to treatment. It is known that patients whose grade rises during surveillance do better than patients diagnosed with the same grade at first diagnosis; in other words, the risk of “missing the opportunity” with surveillance is not as great as feared.

Anxiety is also a medical reason

In about 10% of patients under surveillance, the anxiety of being under constant monitoring reaches a significant level. The EAU recognises this as a valid reason to switch to treatment, but recommends offering psychological support first. Our experience also shows that a patient who has understood the true nature of the disease experiences active surveillance not as waiting but as a conscious choice.

Focal Therapy: Is It Possible to Target Only the Tumour?

Focal therapy aims to destroy only the area containing the cancer, rather than the whole prostate, using high-intensity focused ultrasound (HIFU), freezing (cryotherapy), an electric field (IRE) or a similar form of energy. The logic is simple: if the location of the tumour can now be seen on MRI, it should be possible to remove only the diseased tissue while preserving the nerves, the urinary sphincter muscle and the urethra. Functional results confirm this expectation: one year after focal HIFU, only a 9% decline in sexual function scores is observed, whereas in treatments that destroy the whole prostate this figure rises to 43%; the continence rate is above 95%.

What do the guidelines say?

Both guidelines approach focal therapy with caution and state this clearly.

• EAU 2026 addresses focal therapy under the heading of “investigational treatments”. It states that the quality of evidence is low, that studies are mostly single-centre and non-comparative, and that there is no standard pathway for patient selection and follow-up. As a result, it recommends that focal therapy be performed within clinical trials or prospective registry programmes.
• NCCN 2026 has added a new section to its guideline this year called “principles of focal therapy”. It emphasises that the standard approach in low-risk patients is active surveillance and asks that focal therapy be approached with care in newly diagnosed patients. In intermediate-risk patients it recommends focal therapy only within a clinical trial, preferably one comparing it with standard treatment. In high-risk patients it stresses that results are likely to be worse than standard treatment, because in these patients the cancer may also be present outside the treated area.

What do the data show?

The largest data set on focal therapy comes from the HEAT and ICE registries in the United Kingdom. The latest analysis, published in July 2026, evaluated 3,477 patients from 14 centres (most treated with HIFU); 48% of the patients were in the favourable intermediate, 23% in the unfavourable intermediate and 25% in the high-risk group. At ten years, death from prostate cancer was 0.13% and metastasis 3.3%; however, over the same period 33% of patients had needed repeat focal treatment and 30% radical treatment such as surgery or radiotherapy. In the authors' own words, up to two sessions of focal therapy can be considered as an option alongside radical treatment in “well-selected” patients; however, the study is observational, meaning the patients were not randomised.

What is missing?

A large randomised trial directly comparing focal therapy with surgery or radiotherapy has not yet been published. The three-year results of the FARP study in Norway have only been presented as a congress abstract. To fill this gap, the 306-patient PART trial in the United Kingdom and the 356-patient ENFORCE trial in the Netherlands are ongoing; both aim to prove that focal therapy is not worse than radical treatment in intermediate-risk patients. Until the results arrive, focal therapy should remain an option applied in patients who meet certain conditions, with its limits understood and with a commitment to regular MRI and biopsy follow-up.

The suitable candidate profile can be summarised as follows: a single, well-defined tumour on MRI, ISUP 2 (selected ISUP 3) grade, PSA below 20, demonstration by both targeted and systematic biopsy that the tumour is not present in the rest of the prostate, and a patient who gives high priority to preserving function. In low-risk patients active surveillance, and in high-risk patients radical treatment, is superior to focal therapy.

Surgery: When the Disease Threatens Life

Surgery, that is, removal of the prostate (radical prostatectomy), is the main treatment aimed at eliminating the cancer completely; radiation therapy (radiotherapy) is the other option used for the same purpose. Guidelines define these two paths as the standard treatment for unfavourable intermediate-risk and high-risk patients with a life expectancy of more than ten years. In the favourable intermediate-risk group, active surveillance, surgery and radiotherapy are presented as options of equal weight; the decision is made together according to the patient's priorities.

Who needs surgery?

• Intermediate-risk patients with grade ISUP 3 or higher, PSA above 10, or a tumour involving a significant part of the prostate.
• All high-risk patients: PSA above 20, grade ISUP 4–5 or extension beyond the capsule.
• Patients in whom progression is detected on biopsy during active surveillance.
• Patients who meet the surveillance criteria but choose treatment after an informed decision.

Surgery: robotic radical prostatectomy

The prostate is removed together with its capsule and the seminal vesicles; the bladder is then reconnected to the urethra. Compared with open surgery, robotic surgery provides less bleeding, a shorter hospital stay and earlier urinary control; in ten-year comparisons with laparoscopic surgery, the “quality” of continence and sexual function was found to be higher with the robotic approach. Nerve-sparing technique, intraoperative frozen-section examination (NeuroSAFE) and preservation of urethral length are methods that aim to preserve function without compromising cancer control. In high-risk patients an extended lymph node dissection is added to the operation. One of the most important advantages of surgery is that the removed tissue can be examined completely and any additional treatment can be planned accordingly. We describe the steps of the operation in our article on robotic surgery for prostate cancer.

Radiotherapy

Image-guided intensity-modulated radiation therapy is the modern standard method. Hypofractionated schedules that shorten the treatment time are recommended by EAU 2026 for intermediate-risk patients; in the PACE-B trial, five-session stereotactic treatment was not inferior to the conventional schedule, with a 95.8% disease-free rate at five years. Hormone therapy is added to radiotherapy for four to six months in intermediate-risk patients and for two to three years in high-risk patients; in the MARCAP analysis covering 12 randomised trials, this addition significantly improved survival. Giving an additional dose to the main tumour visible on MRI (the FLAME trial) reduced the ten-year recurrence rate from 29% to 14%.

Surgery or radiotherapy?

The ProtecT trial showed that the cancer outcomes of these two paths did not differ at 15 years. The difference lies in the side-effect profile: after surgery, urinary incontinence and loss of sexual function appear earlier and more markedly and partly improve over time; after radiotherapy, bowel and urinary complaints and effects related to hormone therapy are more prominent, and loss of sexual function develops more slowly. Surgery generally comes to the fore in young, healthy patients without urinary complaints; radiotherapy in older patients, those with other illnesses or those with a high surgical risk. The final decision should be made in an assessment involving both urology and radiation oncology specialists.

The Studies That Shape These Decisions

The studies below are the real data on which the principles described above are based. Each was carried out in a different period and in a different patient group, so their results should be read together.

The combined message of these studies is clear: for low-risk prostate cancer, early and aggressive treatment does not prolong life; in contrast, in intermediate–high-risk disease, if life expectancy is sufficient, timely radical treatment markedly reduces metastasis and death from cancer. Focal therapy is a promising bridge between the two, but its level of evidence is not yet complete.

At a Glance: Which Path for Which Patient?

Conclusion: Three Questions to Ask Your Doctor

In prostate cancer, the right decision begins with correctly measuring the real danger of the disease. Modern MRI, targeted biopsy, PSMA PET and genomic tests allow us increasingly to distinguish the patient who truly needs treatment from the patient who will never need it. The most important message of the 15–25 years of data we have today is that low-risk prostate cancer does not threaten the life of most men and that these patients can be spared the side effects of treatment. The same data also show beyond doubt that timely radical treatment saves lives in intermediate- and high-risk disease.

The information in this article provides a general framework; no patient's decision can be read from a table alone. When your diagnostic report, your MRI images, your general health and your life priorities are evaluated together, the right path for you is determined. When you go to see your doctor, I recommend asking these three questions:

1. “What is my risk group, and which findings determined it?”
2. “In my situation, what are the expected cancer outcomes and side effects of surveillance, focal therapy and radical treatment?”
3. “How much time do I have for this decision?”

In prostate cancer there is almost always enough time to think, to get a second opinion and to reach a decision together. For the first steps after diagnosis, you may also find our article I have just been diagnosed with cancer: what should I do? helpful.