Review Article| Volume 21, ISSUE 1, P115-123, February 2023

Download started.


Modern Active Surveillance in Prostate Cancer: A Narrative Review

Published:September 07, 2022DOI:


      The use of PSA screening has led to downstaging and downgrading of prostate cancer at diagnosis, increasing detection of indolent disease. Active surveillance aims to reduce over-treatment by delaying or avoiding radical treatment and its associated morbidity. However, there is not a consensus on the selection criteria and monitoring schedules that should be used. This article aims to summarize the evidence supporting the safety of active surveillance, the current selection criteria recommended and in use, the incidence of active surveillance, barriers existing to its uptake and future developments in patient selection.


      To read this article in full you will need to make a payment

      Purchase one-time access:

      Academic & Personal: 24 hour online accessCorporate R&D Professionals: 24 hour online access
      One-time access price info
      • For academic or personal research use, select 'Academic and Personal'
      • For corporate R&D use, select 'Corporate R&D Professionals'


      Subscribe to Clinical Genitourinary Cancer
      Already a print subscriber? Claim online access
      Already an online subscriber? Sign in
      Institutional Access: Sign in to ScienceDirect


        • Dee EC
        • Nezolosky MD
        • Chipidza FE
        • et al.
        Prostate cancer-specific mortality burden by risk group among men with localized disease: Implications for research and clinical trial priorities.
        The Prostate. 2020; 80: 1128-1133
        • Mazariego CG
        • Egger S
        • King MT
        • et al.
        Fifteen year quality of life outcomes in men with localized prostate cancer: population based Australian prospective study.
        BMJ. 2020; 371: m3503
        • Carlsson S
        • Benfante N
        • Alvim R
        • et al.
        Long-term outcomes of active surveillance for prostate cancer: The memorial Sloan Kettering cancer center experience.
        The J Urol. 2020; 203: 1122-1127
        • Bokhorst LP
        • Valdagni R
        • Rannikko A
        • et al.
        A Decade of Active Surveillance in the PRIAS Study: An Update and Evaluation of the Criteria Used to Recommend a Switch to Active Treatment.
        Euro Urol. 2016; 70: 954-960
        • Klotz L
        • Vesprini D
        • Sethukavalan P
        • et al.
        Long-term follow-up of a large active surveillance cohort of patients with prostate cancer.
        J Clin Oncol. 2014; 33: 272-277
        • Epstein JI
        • Zelefsky MJ
        • Sjoberg DD
        • et al.
        A contemporary prostate cancer grading system: A validated alternative to the gleason score.
        Euro Urol. 2016; 69: 428-435
        • D'Amico AV
        • Whittington R
        • Malkowicz SB
        • et al.
        Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer.
        JAMA. 1998; 280: 969-974
        • Holmberg L
        • Bill-Axelson A
        • Helgesen F
        • et al.
        A randomized trial comparing radical prostatectomy with watchful waiting in early prostate cancer.
        New England J Med. 2002; 347: 781-789
        • Bill-Axelson A
        • Holmberg L
        • Garmo H
        • et al.
        Radical prostatectomy or watchful waiting in early prostate cancer.
        New England J Med. 2014; 370: 932-942
        • Wilt TJ
        • Jones KM
        • Barry MJ
        • et al.
        Follow-up of prostatectomy versus observation for early prostate cancer.
        The New England J Med. 2017; 377: 132-142
        • Hamdy FC
        • Donovan JL
        • Athene LJ
        • et al.
        10-Year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer.
        The New England J Med. 2016; 375: 1415-1424
        • Bryant RJ
        • Oxley J
        • Young GJ
        • et al.
        The ProtecT trial: analysis of the patient cohort, baseline risk stratification and disease progression.
        BJU international. 2020; 125: 506-514
        • Kinsella N
        • Helleman J
        • Bruinsma S
        • et al.
        Active surveillance for prostate cancer: A systematic review of contemporary worldwide practices.
        Translational Androl and Urol. 2018; 7: 83-97
        • Godtman RA
        • Holmberg E
        • Khatami A
        • Pihl C-G
        • Stranne J
        • Hugosson J.
        Long-term results of active surveillance in the Göteborg randomized, population-based prostate cancer screening trial.
        Euro Urol. 2016; 70: 760-766
        • Thompson JE
        • Hayen A
        • Landau A
        • et al.
        Medium-term oncological outcomes for extended vs. saturation biopsy and transrectal vs. transperineal biopsy in active surveillance for prostate cancer.
        BJU international. 2015; 115: 884-891
        • Tosoian JJ
        • Mamawala M
        • Epstein JI
        • et al.
        Active Surveillance of Grade Group 1 Prostate Cancer: Long-term Outcomes from a Large Prospective Cohort.
        Euro Urol. 2020; 77: 675-682
        • Selvadurai ED
        • Singhera M
        • Thomas K
        • et al.
        Medium-term Outcomes of Active Surveillance for Localized Prostate Cancer.
        Euro Urol. 2013; 64: 981-987
        • Newcomb LF
        • Thompson IM
        • Boyer HD
        • et al.
        Outcomes of Active Surveillance for Clinically Localized Prostate Cancer in the Prospective, Multi-Institutional Canary PASS Cohort.
        J Urol. 2016; 195: 313-320
        • Marenghi C
        • Alvisi MF
        • Palorini F
        • et al.
        Eleven-year Management of Prostate Cancer Patients on Active Surveillance: What have We Learned?.
        Tumori. 2017; 103: 464-474
        • Bruinsma SM
        • Bangma CH
        • Carroll PR
        • et al.
        Active surveillance for prostate cancer: a narrative review of clinical guidelines.
        Nature Reviews Urol. 2016; 13: 151
        • Bekelman JE
        • Rumble RB
        • Freedland SJ.
        Clinically localized prostate cancer: ASCO clinical practice guideline endorsement of an AUA/ASTRO/SUO guideline summary.
        J Oncol Practice. 2018; 14: 618-624
        • Mottet N.BJ
        • Briers E.
        • Bolla M.
        • et al.
        Members of the EAU – ESTRO – ESUR –SIOG Prostate Cancer Guidelines Panel. EAU – ESTRO – ESUR – SIOG Guidelines on Prostate Cancer.
        ([cited 15/09/2021])EAU Guidelines Edn presented at the EAU Annual Congress Milan 2021 [Internet]. EAU Guidelines Office, Arnhem, The Netherlands2021 ([cited 15/09/2021] Available at)
        • Kır GMD
        • Seneldir HMD
        • Gumus EMD.
        Outcomes of Gleason score 3 + 4 = 7 prostate cancer with minimal amounts (<6%) vs. ≥6% of Gleason pattern 4 tissue in needle biopsy specimens.
        Annals of Diagnostic Pathol. 2015; 20: 48-51
        • Su ZT
        • Patel HD
        • Epstein JI
        • Pavlovich CP
        • Allaf ME.
        Downgrading of grade group 2 intermediate-risk prostate cancer from biopsy to radical prostatectomy: Comparison of outcomes and predictors to identify potential candidates for active surveillance.
        Cancer. 2020; 126: 1632-1639
        • Patel HD
        • Tosoian JJ
        • Carter HB
        • Epstein JI.
        Adverse pathologic findings for men electing immediate radical prostatectomy: Defining a favorable intermediate-risk group.
        JAMA Oncology. 2018; 4: 89-92
        • Enikeev D
        • Morozov A
        • Taratkin M
        • et al.
        Active surveillance for intermediate-risk prostate cancer: Systematic review and meta-analysis of current protocols and outcomes.
        Clin genitourinary cancer. 2020; 18: e739-ee53
        • Kweldam CF
        • Kümmerlin IP
        • Nieboer D
        • et al.
        Disease-specific survival of patients with invasive cribriform and intraductal prostate cancer at diagnostic biopsy.
        Modern Pathol. 2016; 29: 630-636
      1. NICE Guidance – Prostate cancer: diagnosis and management. BJU International. 2019;124:9-26.

        • Lilja H.
        Biology of prostate-specific antigen.
        Urology. 2003; 62: 27-33
        • Kevin KY.
        Beyond prostate-specific antigen: Alternatives for prostatic neoplasm screening.
        Boston University, Boston, Massachusetts2014
        • Zapatero Rodríguez J
        • O'Kennedy R
        New approaches for the development of diagnostic systems for prostate cancer.
        Asian Hospital and Healthcare Manag. 2017; 36: 18-23
        • Eggener SE
        • Mueller A
        • Berglund RK
        • et al.
        A multi-institutional evaluation of active surveillance for low risk prostate cancer.
        J Urol. 2013; 189: S19-S25
        • Lilja H
        • Ulmert D
        • Vickers AJ.
        Prostate-specific antigen and prostate cancer: prediction, detection and monitoring.
        Nature Reviews Can. 2008; 8: 268
        • Yamamoto T
        • Musunuru B
        • Vesprini D
        • et al.
        Metastatic prostate cancer in men initially treated with active surveillance.
        The J Urol. 2016; 195: 1409-1414
        • Tosoian JJ
        • Loeb S
        • Feng Z
        • et al.
        Association of [-2]proPSA with biopsy reclassification during active surveillance for prostate cancer.
        J Urol. 2012; 188: 1131-1136
        • Hirama H
        • Sugimoto M
        • Ito K
        • Shiraishi T
        • Kakehi Y.
        The impact of baseline [-2]proPSA-related indices on the prediction of pathological reclassification at 1 year during active surveillance for low-risk prostate cancer: the Japanese multicenter study cohort.
        J Cancer Res Clin Oncol. 2014; 140: 257-263
        • Lin DW
        • Newcomb LF
        • Brown MD
        • et al.
        Evaluating the Four Kallikrein Panel of the 4Kscore for Prediction of High-grade Prostate Cancer in Men in the Canary Prostate Active Surveillance Study.
        Euro Urol. 2017; 72: 448-454
        • Lam TB
        • MacLennan SJ
        • Willemse PP
        • et al.
        PT077 - EAU-EANM-ESTRO-ESUR-SIOG Prostate Cancer Guideline Panel consensus statements for active surveillance for localized prostate cancer from an international collaborative study (DETECTIVE study).
        Euro Urol Open Science. 2020; 19: e1814-e18e5
        • Gallagher KM
        • Christopher E
        • Cameron AJ
        • et al.
        Four-year outcomes from a multiparametric magnetic resonance imaging (MRI)-based active surveillance programme: PSA dynamics and serial MRI scans allow omission of protocol biopsies.
        BJU International. 2019; 123: 429-438
        • Herrera-Caceres JO
        • Wettstein MS
        • Goldberg H
        • et al.
        Utility of digital rectal examination in a population with prostate cancer treated with active surveillance.
        Can Urol Assoc J. 2020; 14: E453-E4e7
        • Lam TBL
        • MacLennan S
        • Willemse PM
        • et al.
        EAU-EANM-ESTRO-ESUR-SIOG Prostate Cancer Guideline Panel Consensus Statements for Deferred Treatment with Curative Intent for Localized Prostate Cancer from an International Collaborative Study (DETECTIVE Study).
        Eur Urol. 2019; 76: 790-813
        • Conti SL
        • Dall'Era M
        • Fradet V
        • Cowan JE
        • Simko J
        • Carroll PR.
        Pathological outcomes of candidates for active surveillance of prostate cancer.
        The J Urol. 2009; 181: 1628-1634
        • Xiang J
        • Yan H
        • Li J
        • Wang X
        • Chen H
        • Zheng X.
        Transperineal versus transrectal prostate biopsy in the diagnosis of prostate cancer: a systematic review and meta-analysis.
        World J Surg Oncol. 2019; 17: 31
        • Ong WL
        • Weerakoon M
        • Huang S
        • et al.
        Transperineal biopsy prostate cancer detection in first biopsy and repeat biopsy after negative transrectal ultrasound-guided biopsy: the Victorian Transperineal Biopsy Collaboration experience.
        BJU International. 2015; 116: 568-576
      2. NCCN Clinical Practice Guidelines in Oncology (NCCN Guidelines) Prostate Cancer2022. Available at:

        • Thurtle D
        • Barrett T
        • Thankappan-Nair V
        • et al.
        Progression and treatment rates using an active surveillance protocol incorporating image-guided baseline biopsies and multiparametric magnetic resonance imaging monitoring for men with favorable-risk prostate cancer.
        BJU international. 2018; 122: 59-65
        • Weinreb JC
        • Barentsz JO
        • Choyke PL
        • et al.
        PI-RADS Prostate Imaging - Reporting and Data System: 2015, Version 2.
        Euro Urol. 2016; 69: 16-40
        • Rouvière O
        • Puech P
        • Renard-Penna R
        • et al.
        Use of prostate systematic and targeted biopsy on the basis of multiparametric MRI in biopsy-naive patients (MRI-FIRST): a prospective, multicenter, paired diagnostic study.
        Lancet Oncol. 2019; 20: 100-109
        • Liss MA
        • Newcomb LF
        • Zheng Y
        • et al.
        Magnetic resonance imaging for the detection of high grade cancer in the canary prostate active surveillance study.
        J Urol. 2020; 204: 701-706
        • Klotz L
        • Loblaw A
        • Sugar L
        • et al.
        Active surveillance magnetic resonance imaging study (ASIST): Results of a randomized multicenter prospective trial.
        Euro Urol. 2019; 75: 300-309
        • Klotz L
        • Pond G
        • Loblaw A
        • et al.
        Randomized study of systematic biopsy versus magnetic resonance imaging and targeted and systematic biopsy in men on active surveillance (ASIST): 2-year postbiopsy follow-up.
        Eur Urol. 2020; 77: 311-317
        • Hettiarachchi D
        • Geraghty R
        • Rice P
        • et al.
        Can the use of serial multiparametric magnetic resonance imaging during active surveillance of prostate cancer avoid the need for prostate biopsies?—A systematic diagnostic test accuracy review.
        Euro Urol Oncol. 2021; 4: 426-436
        • Moore CM
        • Giganti F
        • Albertsen P
        • et al.
        Reporting magnetic resonance imaging in men on active surveillance for prostate cancer: The PRECISE recommendations—A report of a European school of oncology task force.
        Euro Urol. 2016; 71: 648-655
        • Caglic I
        • Sushentsev N
        • Gnanapragasam VJ
        • et al.
        MRI-derived PRECISE scores for predicting pathologically-confirmed radiological progression in prostate cancer patients on active surveillance.
        European Radiol. 2021; 31: 2696-2705
        • Cullen J
        • Rosner IL
        • Brand TC
        • et al.
        A Biopsy-based 17-gene Genomic Prostate Score Predicts Recurrence After Radical Prostatectomy and Adverse Surgical Pathology in a Racially Diverse Population of Men with Clinically Low- and Intermediate-risk Prostate Cancer.
        Euro Urol. 2015; 68: 123-131
        • Lin DW
        • Zheng Y
        • McKenney JK
        • et al.
        17-Gene genomic prostate score test results in the canary prostate active surveillance study (PASS) cohort.
        J Clin Oncol. 2020; 38: 1549-1557
        • Cuzick J
        • Berney D
        • Fisher G
        • et al.
        Prognostic value of a cell cycle progression signature for prostate cancer death in a conservatively managed needle biopsy cohort.
        British journal of cancer. 2012; 106: 1095-1099
        • Kaul S
        • Wojno KJ
        • Stone S
        • et al.
        Clinical outcomes in men with prostate cancer who selected active surveillance using a clinical cell cycle risk score.
        Personalized medicine. 2019; 16: 491-499
        • Manceau C
        • Fromont G
        • Beauval J-B
        • et al.
        Biomarker in active surveillance for prostate cancer: A systematic review.
        Cancers. 2021; 13: 4251
        • Herlemann A
        • Huang H-C
        • Alam R
        • et al.
        Decipher identifies men with otherwise clinically favorable-intermediate risk disease who may not be good candidates for active surveillance.
        Prostate cancer and prostatic diseases. 2020; 23: 136-143
        • Blume-Jensen P
        • Berman DM
        • Rimm DL
        • et al.
        Development and clinical validation of an in situ biopsy-based multimarker assay for risk stratification in prostate cancer.
        Clinical cancer research. 2015; 21: 2591-2600
        • Loeb S
        • Byrne N
        • Makarov DV
        • Lepor H
        • Walter D.
        Use of conservative management for low-risk prostate cancer in the veterans affairs integrated health care system from 2005-2015.
        JAMA. 2018; 319: 2231-2233
        • Loeb S
        • Folkvaljon Y
        • Curnyn C
        • Robinson D
        • Bratt O
        • Stattin P
        Uptake of active surveillance for very-low-risk prostate cancer in Sweden.
        JAMA oncology. 2017; 3: 1393-1398
      3. Papa N OCM, James E, Millar J. Prostate Cancer in Australian and New Zealand Men: Patterns of care within PCOR-ANZ 2015-2018. Melbourne, Victoria; 2021.

        • Volk RJ
        • McFall SL
        • Cantor SB
        • et al.
        It's not like you just had a heart attack’: decision-making about active surveillance by men with localized prostate cancer.
        Psycho-Oncology. 2014; 23: 467-472
        • Xu J
        • Victoria Neale A
        • Dailey RK
        • Eggly S
        • Schwartz KL
        Patient Perspective on Watchful Waiting/Active Surveillance for Localized Prostate Cancer.
        The J the Am Board of Family Med. 2012; 25: 763
        • Evans MA
        • Millar JL
        • Earnest A
        • et al.
        Active surveillance of men with low risk prostate cancer: evidence from the Prostate Cancer Outcomes Registry–Victoria.
        Med J Australia. 2018; 208: 439-443
        • Loeb S
        • Curnyn C
        • Fagerlin A
        • et al.
        Qualitative study on decision-making by prostate cancer physicians during active surveillance.
        BJU International. 2017; 120: 32-39
        • Kwan TN
        • Spremo S
        • Teh AYM
        • McHarg D
        • Thangasamy I
        • Woo HH.
        Performance of Ga-68 PSMA PET/CT for diagnosis and grading of local prostate cancer.
        Prostate international. 2021; 9: 107-112
        • Scheltema MJ
        • Chang JI
        • Stricker PD
        • et al.
        Diagnostic accuracy of 68Ga-prostate-specific membrane antigen (PSMA) positron-emission tomography (PET) and multiparametric (mp) MRI to detect intermediate-grade intra-prostatic prostate cancer using whole-mount pathology: impact of the addition of 68Ga-PSMA PET to mp MRI.
        BJU international. 2019; 124: 42-49
        • Emmett L
        • Buteau J
        • Papa N
        • et al.
        The additive diagnostic value of prostate-specific membrane antigen positron emission tomography computed tomography to multiparametric magnetic resonance imaging triage in the diagnosis of prostate cancer (PRIMARY): A prospective multicenter study.
        European urology. 2021; 80: 682-689
        • Amin A
        • Scheltema MJ
        • Shnier R
        • et al.
        The Magnetic Resonance Imaging in Active Surveillance (MRIAS) Trial: Use of Baseline Multiparametric Magneticx Resonance Imaging and Saturation Biopsy to Reduce the Frequency of Surveillance Prostate Biopsies.
        J Urol. 2020; 203: 910-917
        • Kornberg Z
        • Cooperberg MR
        • Spratt DE
        • Feng FY.
        Genomic biomarkers in prostate cancer.
        Translational Androl and Urol. 2018; 7: 459-471
        • Balakrishnan AS
        • Cowan JE
        • Cooperberg MR
        • Shinohara K
        • Nguyen HG
        • Carroll PR.
        Evaluating the safety of active surveillance: Outcomes of deferred radical prostatectomy after an initial period of surveillance.
        J Urol. 2019; 202: 506-510