Active Surveillance Becomes Dominant Strategy for Low-Risk Prostate Cancer, Reaching 93% Among Veterans

Active surveillance has become the predominant initial management strategy for veterans diagnosed with low-risk prostate cancer, with use increasing from 27% in 2005 to 93% in 2024, according to findings published in JAMA.¹ The results demonstrate a substantial shift away from immediate surgery or radiation for cancers considered unlikely to progress rapidly.

Surveillance also expanded substantially among patients with favorable intermediate-risk disease. In this population, use increased from 14% in 2005 to 61% in 2024, suggesting that clinicians are increasingly incorporating tumor characteristics and progression risk into decisions about whether immediate definitive therapy is necessary.¹

Surveillance Use Increased Across 2 Decades

Researchers evaluated 73,042 veterans who were diagnosed between 2005 and 2024 with National Comprehensive Cancer Network low-risk or favorable intermediate-risk prostate cancer. Of these patients, 38,130 were initially managed with active surveillance or watchful waiting, and the median patient age was 65 years.¹

For the analysis, patients were generally classified as receiving surveillance or watchful waiting when they did not undergo definitive treatment within 15 months after diagnostic biopsy and had evidence of subsequent prostate-specific antigen (PSA) monitoring or underwent a confirmatory biopsy before treatment.¹

Among those with favorable intermediate-risk disease, surveillance patterns differed according to the factors driving risk classification. Use increased from 11% to 55% among patients with PSA levels below 10 ng/mL and grade group (GG) 2 disease involving less than 50% of biopsy cores. Among those with GG1 disease and PSA levels of 10 to 20 ng/mL, surveillance increased from 27% to 88%.¹

Older age and a more recent year of diagnosis were independently associated with greater likelihood of surveillance; however, the investigators also identified disparities. Black patients, Hispanic patients, and those living in areas with greater socioeconomic deprivation had lower adjusted odds of receiving surveillance.¹ These differences warrant attention as guideline-concordant surveillance becomes increasingly incorporated into prostate cancer management.

Active Surveillance Aims to Reduce Overtreatment

Active surveillance differs from simply withholding treatment. Patients undergo structured monitoring designed to identify changes suggesting that definitive therapy may become necessary. Current guidance recommends serial PSA testing and repeat prostate biopsy, with magnetic resonance imaging used to augment risk stratification rather than replace periodic biopsy.²

The 2026 American Urological Association/American Society for Radiation Oncology guideline recommends active surveillance as the preferred management option for patients with low-risk prostate cancer. For favorable intermediate-risk disease, health care professionals are advised to discuss active surveillance alongside radiation therapy and radical prostatectomy as potential options.²

Avoiding or delaying treatment can reduce exposure to adverse effects associated with prostatectomy and radiation therapy, including urinary, sexual, and bowel dysfunction. Active surveillance preserves the ability to initiate curative-intent treatment if monitoring indicates clinically meaningful progression.^3,4

Long-Term Data Support Surveillance Strategy

Long-term outcomes provide additional support for this approach. In the multicenter Canary Prostate Active Surveillance Study—which included 2155 patients with favorable-risk prostate cancer—the estimated 10-year incidence of metastasis was 1.4%, and prostate cancer–specific mortality was 0.1%.³ Approximately 49% of patients remained free of progression or definitive treatment at 10 years.

Importantly, patients who underwent treatment after several years of surveillance did not experience significantly worse adverse outcomes than those treated earlier following confirmatory biopsy. This reinforces the ability of structured surveillance to delay unnecessary treatment while preserving opportunities for intervention.³

The new VA analysis also indicates that implementation may matter. Surveillance rates within the VA exceeded those previously reported in US community-based practices, which investigators suggested could reflect the integrated system's emphasis on guideline-based care, quality monitoring, continuity, and fewer financial incentives favoring treatment.¹ However, the study could not consistently distinguish active surveillance from watchful waiting and relied on electronic health record information that may have incompletely captured disease stage.¹

Overall, the findings suggest that active surveillance has moved from an underused alternative to the dominant initial management strategy for low-risk prostate cancer within the VA system, aligning real-world practice more closely with contemporary evidence and clinical guidelines.^1,2

REFERENCES

1. Lee G, Bihn JR, Culnan JM, et al. Active Surveillance Use for Favorable-Risk Prostate Cancer in a Veterans Affairs Population. JAMA. Published online August 13, 2026. doi:10.1001/jama.2026.13471

2. Eastham JA, Barocas DA, Chu CE, et al. Clinically Localized Prostate Cancer: AUA/ASTRO Guideline Amendment (2026). J Urol. 2026;216(1):2-11. doi:10.1097/JU.0000000000005060.

3. Newcomb LF, Schenk JM, Zheng Y, et al. Long-Term Outcomes in Patients Using Protocol-Directed Active Surveillance for Prostate Cancer. JAMA. 2024;331(24):2084-2093. doi:10.1001/jama.2024.6695

4. Cooperberg MR, Meeks W, Fang R, Gaylis FD, Catalona WJ, Makarov DV. Time Trends and Variation in the Use of Active Surveillance for Management of Low-risk Prostate Cancer in the US. JAMA Netw Open. 2023;6(3):e231439. doi:10.1001/jamanetworkopen.2023.1439