Active Surveillance in Low-Risk Prostate Cancer Reaches 93%: A JAMA Analysis of 73,042 Patients

KEY FINDINGS

• In low-risk disease: The rate of active surveillance was 27% in 2005 and reached 93% in 2024.
• In favourable intermediate-risk disease: The use of surveillance rose over the same period from 14% to 61%.
• In subgroups: In patients with PSA <10 ng/mL and Grade Group 2 with less than 50% positive biopsy cores, surveillance rose from 11% to 55%; in those with Grade Group 1 and PSA 10-20 ng/mL it rose from 27% to 88%.
• Signals of inequality: Black/African American origin (OR 0.95), Hispanic/Latino origin (OR 0.85) and a higher area deprivation index significantly reduced the choice of surveillance.
• Variation between centres: Overall surveillance rates ranged from 23% to 93% across different VA centres.

Background: Why Active Surveillance?

PSA-based screening saves thousands of lives by catching aggressive prostate cancers early. However, the same screening also leads to the detection of slow-growing tumours that are likely to remain clinically insignificant. This has given rise to the fundamental question that has marked the past two decades of urological practice: must we intervene in every cancer detected?

Active surveillance is a strategy that weighs together the indolence of the natural history of low-risk disease and the permanent effects of radical prostatectomy and radiotherapy on urinary, sexual and bowel function. The protocol typically consists of PSA follow-up every 3-6 months, rectal examination at less frequent intervals, multiparametric MRI and confirmatory biopsies; curative treatment is initiated when progression of disease is detected.

The evidence base for this approach has been strengthened by 15-year ProtecT data: in localized prostate cancer, prostate cancer-specific mortality in the active surveillance, prostatectomy and radiotherapy arms was 3.1%, 2.2% and 2.9% respectively, and the difference between the groups did not reach statistical significance (P=0.53). Against this, rates of metastatic disease and clinical progression ran higher in the active surveillance arm - a critical nuance reminding us that a surveillance strategy requires careful patient selection and disciplined follow-up.

Study Design

The retrospective cohort study, conducted under the PROFOUND-VET research initiative of UCSF, the San Francisco VA Health System and other VA institutions, examined management patterns in patients diagnosed between 2005 and 2024 using national VA data.

Key Results

Change by risk group

Factors affecting the choice of active surveillance (multivariable analysis)

Variation between centres: Overall active surveillance rates range from 23% to 93% between centres. However, in Grade Group 1 patients diagnosed between 2015 and 2024 this variation narrowed markedly; apart from one centre (26%), rates clustered between 60% and 100% in all centres. This picture shows that the area of most homogeneous guideline adherence is pure low-risk disease.

Senior author Professor Matthew R. Cooperberg (UCSF) emphasises that screening saves lives by detecting aggressive cancers early; but that it also detects many slow-growing cancers that do not spread and that should not, other than in rare circumstances, be treated, noting that patients who say they prefer treatment in early-stage disease may need to be better informed.

Implications for Clinical Practice

1. In low-risk disease, active surveillance is no longer the exception but the rule

The AUA/ASTRO guidelines define active surveillance as the preferred approach in low-risk prostate cancer. The VA data prove that this recommendation can be translated into practice almost fully in an integrated system. If radical treatment is being recommended directly to a low-risk patient, the justification for that decision should be documented in detail.

2. Favourable intermediate risk is the new frontier of the debate

The 61% rate shows that surveillance is becoming increasingly legitimate in selected Grade Group 2 patients. In this group the decision requires a holistic assessment of MRI findings, tumour burden on targeted biopsy, genomic classifiers, life expectancy and the patient's personal priorities.

3. The result is a product of system design

The reason the VA has reached high surveillance rates is not physician preference alone; quality monitoring, physician feedback mechanisms and long-term continuity of care produced this result. Safe implementation of active surveillance requires recall systems that keep patients from dropping out of follow-up, standard PSA intervals and infrastructure for planned MRI/confirmatory biopsy. Surveillance is not "not treating"; it is a structured and disciplined treatment strategy.

4. The inequality data must not be overlooked

Lower surveillance rates in Black and Hispanic patients and in those living in socioeconomically disadvantaged areas is a finding that deserves attention in terms of the quality of counselling and patient-physician communication. The knowledge that prostate cancer may follow a more aggressive course in Black patients is clinically valid; but this should not mean that surveillance is automatically ruled out in pure low-risk disease.

5. From the standpoint of patient communication

The greatest concern of a patient diagnosed with low-risk prostate cancer is the feeling that "nothing is being done". Yet active surveillance is a strategy in which the cancer is kept under close observation and curative treatment can be applied at full effectiveness when there is any sign of progression. Conveying this framework clearly to the patient is decisive in preventing unnecessary requests for surgery and the associated loss of quality of life.

Limitations

• The retrospective design and the possibility that electronic health record data - particularly on staging - may be incomplete.
• The inability to distinguish clearly in the dataset between active surveillance and watchful waiting; the aim and intensity of follow-up of these two strategies differ.
• The classification criteria used do not correspond exactly to the NCCN risk groups.
• The VA population is almost entirely male and of a particular age and socioeconomic profile; direct generalisation of the findings to the general population is limited.
• The study reports surveillance rates; it does not assess the oncological outcomes of patients under surveillance.

Conclusion

A rate rising from 27% to 93% within twenty years documents a paradigm shift of a scale rarely encountered in urological practice. This is one of the most concrete successes of evidence-based medicine, showing that overdiagnosis does not inevitably turn into overtreatment.

The picture is nevertheless not complete. The difference between centres in the 23%-93% range, the uncertainty in favourable intermediate-risk disease and differences in preference between ethnic and socioeconomic groups form the agenda for the period ahead. The real goal is not to maximise the surveillance rate; it is to guide every patient, through accurate and transparent information, towards the strategy appropriate to their own biology, life expectancy and values.

References

• Lee G, Bihn JR, Culnan JM, et al. Active surveillance use for favorable-risk prostate cancer in a Veterans Affairs population. JAMA. 2026. doi:10.1001/jama.2026.13471
• Clarke H. Active surveillance use for low-risk prostate cancer reaches 93% in VA System. Urology Times, 14 August 2026.
• University of California, San Francisco. For early prostate cancer "active surveillance" is now #1 choice. Press release, 13 August 2026.
• Eastham JA, Barocas D, Chu C, et al. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline Amendment (2026). J Urol. doi:10.1097/JU.0000000000005060
• Hamdy FC, Donovan JL, Lane JA, et al. Fifteen-year outcomes after monitoring, surgery, or radiotherapy for prostate cancer (ProtecT). N Engl J Med. 2023;388(17):1547-1558.