Official reprint from UpToDate®
www.uptodate.com ©2017 UpToDate, Inc. and/or its affiliates. All Rights Reserved.

Active surveillance for men with low-risk, clinically localized prostate cancer

Laurence Klotz, MD
Section Editors
Nicholas Vogelzang, MD
W Robert Lee, MD, MS, MEd
Jerome P Richie, MD, FACS
Deputy Editor
Michael E Ross, MD


Active surveillance for men with prostate cancer involves the avoidance or postponement of immediate therapy combined with careful surveillance; definitive treatment is then offered if there is evidence that the patient is at increased risk for disease progression. Active surveillance is the preferred option for the initial management of most men with localized low-risk prostate cancer [1,2].

Active surveillance differs from watchful waiting (observation), which is based upon the premise that men will not benefit from definitive treatment of clinically localized prostate cancer because of limited life expectancy, comorbidity, and the prolonged natural history of the prostate cancer [3]. For patients managed with watchful waiting, the decision is made at the outset to forego definitive treatment and to provide systemic or local treatment to palliate symptoms if disease progresses locally or at distant metastatic sites.

Key aspects of active surveillance for patients with localized low-risk prostate cancer will be reviewed here, including:


Criteria for patient selection

To continue reading this article, you must log in with your personal, hospital, or group practice subscription. For more information on subscription options, click below on the option that best describes you:

Subscribers log in here

Literature review current through: Nov 2017. | This topic last updated: Jul 13, 2017.
The content on the UpToDate website is not intended nor recommended as a substitute for medical advice, diagnosis, or treatment. Always seek the advice of your own physician or other qualified health care professional regarding any medical questions or conditions. The use of this website is governed by the UpToDate Terms of Use ©2017 UpToDate, Inc.
  1. Chen RC, Rumble RB, Loblaw DA, et al. Active Surveillance for the Management of Localized Prostate Cancer (Cancer Care Ontario Guideline): American Society of Clinical Oncology Clinical Practice Guideline Endorsement. J Clin Oncol 2016.
  2. http://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf (Accessed on February 18, 2016).
  3. Dahabreh IJ, Chung M, Balk EM, et al. Active surveillance in men with localized prostate cancer: a systematic review. Ann Intern Med 2012; 156:582.
  4. Dall'Era MA, Albertsen PC, Bangma C, et al. Active surveillance for prostate cancer: a systematic review of the literature. Eur Urol 2012; 62:976.
  5. Thompson IM, Goodman PJ, Tangen CM, et al. The influence of finasteride on the development of prostate cancer. N Engl J Med 2003; 349:215.
  6. Welch HG, Schwartz LM, Woloshin S. Prostate-specific antigen levels in the United States: implications of various definitions for abnormal. J Natl Cancer Inst 2005; 97:1132.
  7. Eggener SE, Scardino PT, Walsh PC, et al. Predicting 15-year prostate cancer specific mortality after radical prostatectomy. J Urol 2011; 185:869.
  8. Thompson I, Thrasher JB, Aus G, et al. Guideline for the management of clinically localized prostate cancer: 2007 update. J Urol 2007; 177:2106.
  9. Musunuru HB, Klotz L, Vespirini D, et al. Cautionary tale of active surveillance in intermediate-risk patients: Overall and cause-specific survival in the Sunnybrook experience. J Clin Oncol 33, 2015 (suppl 7; abstr 163)
  10. Yamamoto T, Musunuru B, Vesprini D, et al. Metastatic Prostate Cancer in Men Initially Treated with Active Surveillance. J Urol 2016; 195:1409.
  11. Loeb S, Roehl KA, Helfand BT, Catalona WJ. Complications of open radical retropubic prostatectomy in potential candidates for active monitoring. Urology 2008; 72:887.
  12. Eggener SE, Mueller A, Berglund RK, et al. A multi-institutional evaluation of active surveillance for low risk prostate cancer. J Urol 2009; 181:1635.
  13. 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. Eur Urol 2016; 70:954.
  14. Sundi D, Ross AE, Humphreys EB, et al. African American men with very low-risk prostate cancer exhibit adverse oncologic outcomes after radical prostatectomy: should active surveillance still be an option for them? J Clin Oncol 2013; 31:2991.
  15. Duffield AS, Lee TK, Miyamoto H, et al. Radical prostatectomy findings in patients in whom active surveillance of prostate cancer fails. J Urol 2009; 182:2274.
  16. Fleshner NE, Lucia MS, Egerdie B, et al. Dutasteride in localised prostate cancer management: the REDEEM randomised, double-blind, placebo-controlled trial. Lancet 2012; 379:1103.
  17. Shappley WV 3rd, Kenfield SA, Kasperzyk JL, et al. Prospective study of determinants and outcomes of deferred treatment or watchful waiting among men with prostate cancer in a nationwide cohort. J Clin Oncol 2009; 27:4980.
  18. Bul M, Zhu X, Valdagni R, et al. Active surveillance for low-risk prostate cancer worldwide: the PRIAS study. Eur Urol 2013; 63:597.
  19. Godtman RA, Holmberg E, Khatami A, et al. Outcome following active surveillance of men with screen-detected prostate cancer. Results from the Göteborg randomised population-based prostate cancer screening trial. Eur Urol 2013; 63:101.
  20. Rider JR, Sandin F, Andrén O, et al. Long-term outcomes among noncuratively treated men according to prostate cancer risk category in a nationwide, population-based study. Eur Urol 2013; 63:88.
  21. van den Bergh RC, Albertsen PC, Bangma CH, et al. Timing of curative treatment for prostate cancer: a systematic review. Eur Urol 2013; 64:204.
  22. 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 2015; 33:272.
  23. Tosoian JJ, Mamawala M, Epstein JI, et al. Intermediate and Longer-Term Outcomes From a Prospective Active-Surveillance Program for Favorable-Risk Prostate Cancer. J Clin Oncol 2015; 33:3379.
  24. Loeb S, Folkvaljon Y, Makarov DV, et al. Five-year nationwide follow-up study of active surveillance for prostate cancer. Eur Urol 2015; 67:233.
  25. Bill-Axelson A, Holmberg L, Garmo H, et al. Radical prostatectomy or watchful waiting in early prostate cancer. N Engl J Med 2014; 370:932.
  26. Wilt TJ, Brawer MK, Jones KM, et al. Radical prostatectomy versus observation for localized prostate cancer. N Engl J Med 2012; 367:203.
  27. Wilt TJ, Jones KM, Barry MJ, et al. Follow-up of Prostatectomy versus Observation for Early Prostate Cancer. N Engl J Med 2017; 377:132.
  28. Hamdy FC, Donovan JL, Lane JA, et al. 10-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Localized Prostate Cancer. N Engl J Med 2016; 375:1415.
  29. Donovan JL, Hamdy FC, Lane JA, et al. Patient-Reported Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer. N Engl J Med 2016; 375:1425.
  30. Hayes JH, Ollendorf DA, Pearson SD, et al. Active surveillance compared with initial treatment for men with low-risk prostate cancer: a decision analysis. JAMA 2010; 304:2373.
  31. Klotz L. Active surveillance for favorable-risk prostate cancer: who, how and why? Nat Clin Pract Oncol 2007; 4:692.
  32. Dall'Era MA, Cooperberg MR, Chan JM, et al. Active surveillance for early-stage prostate cancer: review of the current literature. Cancer 2008; 112:1650.
  33. Latini DM, Hart SL, Knight SJ, et al. The relationship between anxiety and time to treatment for patients with prostate cancer on surveillance. J Urol 2007; 178:826.
  34. Klotz L. Active surveillance for prostate cancer: trials and tribulations. World J Urol 2008; 26:437.
  35. Dall'Era MA, Konety BR, Cowan JE, et al. Active surveillance for the management of prostate cancer in a contemporary cohort. Cancer 2008; 112:2664.
  36. Bailey DE, Mishel MH, Belyea M, et al. Uncertainty intervention for watchful waiting in prostate cancer. Cancer Nurs 2004; 27:339.