Cancer Therapy AdvisorActive Surveillance, 20 Years Later: Is Low-risk Prostate Cancer Still Overtreated?

Active Surveillance for Low-Risk Prostate Cancer: A Decade of Progress and the Challenge of Overtreatment

The management of low-risk prostate cancer has seen a significant shift over the past decade, with active surveillance — first described explicitly in 2002 — increasingly becoming the preferred approach. Despite this progress, the overtreatment of low-risk disease remains a concern, highlighting the need for further refinement in patient selection and monitoring strategies.

Key Points

• Active surveillance involves monitoring the course of the disease with the expectation to intervene if the cancer progresses.
• In 2010, the National Comprehensive Cancer Network (NCCN) first recommended incorporating active surveillance into clinical practice in its prostate cancer guidelines.
• The use of active surveillance in more than 40,000 men with very low-risk prostate cancer increased from 11.6% in 2010 to 27.3% in 2013.
• By 2017, several national urology and oncology associations recommended active surveillance as the best available care option for patients with very low-risk, clinically localized prostate cancer.
• A study published in April 2023 reported that the percentage of patients with low-risk prostate cancer opting for active surveillance or watchful waiting increased from 16% in 2010 to 60% in 2018.
• Despite these advancements, the authors concluded that overtreatment of low-risk disease remains excessive and suggested that an optimal rate of active surveillance in low-risk prostate cancer would be around 80%.

Most men with favorable-risk prostate cancer are not destined to die of their disease, even in the absence of treatment. The challenge is to identify the subset that harbor more aggressive disease early enough that curative therapy is still a possibility.
— Laurence Klotz, MD, a Toronto urologist and one of the early advocates of active surveillance

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