EVIDENCE & GUIDELINES
Evidence for Active Surveillance
A research-based overview of why Active Surveillance is a well-supported option for many men with low-risk prostate cancer
This page brings together key Active Surveillance guidelines and supporting evidence for prostate cancer, including major clinical recommendations, long-term research, and source documents.
Active Surveillance for prostate cancer is supported by both major medical guidelines and long-term clinical research.
Over the past two decades, it has become a standard approach for many men with low-risk localized prostate cancer. That shift happened because the evidence has shown that, when carefully monitored, Active Surveillance can offer very low rates of prostate cancer death, while allowing many men to avoid or delay treatment and its side effects.
KEY TAKEAWAYS
Here are some of the main things the evidence shows:
- Active Surveillance is supported by major medical guidelines for men with low-risk localized prostate cancer.
- Long-term studies show that the risk of dying from prostate cancer remains very low for appropriately selected men on Active Surveillance.
- Many men stay on Active Surveillance for years without needing treatment.
- Some men will eventually need treatment, but careful monitoring helps doctors catch changes early.
- For many men with low-risk prostate cancer, Active Surveillance is a well-supported way to delay or avoid treatment side effects while still staying closely monitored.
JUMP TO SECTION
Major Guidelines Supporting Active Surveillance
National Comprehensive Cancer Network (NCCN)
United StatesThe National Comprehensive Cancer Network (NCCN) supports Active Surveillance strongly for men with lower-risk prostate cancer. NCCN patient guidance says that for many patients, especially those with low-risk prostate cancer, Active Surveillance or observation may be better options than treatment right away.
American Urological Association / American Society for Radiation Oncology (AUA / ASTRO)
United StatesThe American Urological Association and the American Society for Radiation Oncology (AUA / ASTRO) say that Active Surveillance is the preferred management option for men with low-risk localized prostate cancer. The guideline also says that some carefully selected men with favorable intermediate-risk disease may be considered for Active Surveillance when other features are reassuring, such as low PSA density and low tumor volume.
Cancer Care Ontario (CCO)
CanadaCancer Care Ontario (CCO) states clearly that for men with low-risk localized prostate cancer, Active Surveillance is the preferred disease management strategy. The guideline also says that some carefully selected men with low-volume Gleason 3+4 disease may be considered for Active Surveillance. This guideline was also endorsed by the American Society of Clinical Oncology (ASCO), adding further support from a major North American oncology organization.
National Institute for Health and Care Excellence (NICE)
United KingdomThe National Institute for Health and Care Excellence (NICE) says to offer Active Surveillance for CPG 1 localized prostate cancer. For CPG 2 localized disease, NICE says men should be offered a choice that includes Active Surveillance. For some men with CPG 3 disease, NICE says it may be considered when immediate radical treatment is not chosen, but it should not be offered for CPG 4 or 5 disease.
Health Service Executive (HSE)
IrelandIreland’s Health Service Executive (HSE) national clinical guideline recommends Active Surveillance for men with low-risk prostate cancer who meet appropriate criteria. It also supports Active Surveillance for some carefully selected men with favorable intermediate-risk disease, reflecting a growing international view that some men in this group may also be safely monitored.
European Association of Urology (EAU)
EuropeThe European Association of Urology (EAU) uses some of the strongest language in support of Active Surveillance. It describes Active Surveillance as the first management option for low-risk prostate cancer and says it should be offered as standard of care to suitable patients, including all men with low-risk disease and selected men with favorable intermediate-risk disease.
European Society for Medical Oncology (ESMO)
EuropeThe European Society for Medical Oncology (ESMO) supports Active Surveillance for men with low-risk prostate cancer and also allows it for selected men with favorable intermediate-risk disease. This reflects the broader international view that some carefully chosen men may be safely monitored instead of treated right away.
Cancer Council Australia (CCA)
AustraliaCancer Council Australia (CCA) says that most men with low-risk prostate cancer should be regularly monitored for signs of progression so that curative treatment can begin if it is needed. This supports Active Surveillance as an appropriate first approach for many men with lower-risk disease.
Long-Term Studies Supporting Active Surveillance
ProtecT trial
15-year trialThis major long-term study found that the risk of dying from prostate cancer remained low whether men were monitored, had surgery, or had radiation.
Men in the monitoring group were more likely to have their cancer progress or spread than men who had immediate treatment, but many still avoided treatment for years. The study helped show that immediate treatment does not always improve long-term survival for men with localized prostate cancer.
Hear from the ProtecT trial investigators
This video features the lead investigators behind the ProtecT trial, one of the most important long-term studies in localized prostate cancer.
Sunnybrook / Toronto cohort
Long-term cohortThis Canadian study showed that many men remained on Active Surveillance for years without treatment, while long-term risks of metastasis and prostate cancer death stayed low.
It helped establish Active Surveillance as a credible long-term approach and remains one of the landmark studies in the field.
PASS multicentre cohort
Multicentre cohortThis large modern study from multiple centres also found low rates of metastasis and prostate cancer death over 10 years.
Like other Active Surveillance studies, it showed that some men eventually moved to treatment, while many others continued on surveillance. It also helped show that strong results can be achieved across multiple centres, not just in a single expert program.
PRIAS international study
International prospective studyThe Prostate Cancer Research International Active Surveillance (PRIAS) study helped show that Active Surveillance could be used safely across many centres and countries, not just in one institution.
It became especially important because it used a structured protocol and helped build international confidence that carefully selected men with low-risk prostate cancer could often be monitored safely over time.
Memorial Sloan Kettering cohort
Long-term cohortThis large U.S. cohort found a very low long-term risk of distant metastasis in men with Grade Group 1 disease managed on Active Surveillance.
It added to the evidence from Johns Hopkins and Sunnybrook by showing similarly strong long-term outcomes in another major expert centre with a well-defined monitoring program.
PIVOT trial
Randomized trialThis landmark trial compared surgery with observation in men with localized prostate cancer and found that immediate surgery did not clearly reduce overall or prostate cancer death for many men over long follow-up.
Although PIVOT studied observation rather than modern Active Surveillance, it helped support a major shift in prostate cancer care: not every man with localized prostate cancer needs treatment right away.
Broader review of surveillance cohorts
Review of major Active Surveillance cohortsA broader review of Active Surveillance studies found that long-term risks of metastasis and prostate cancer death were low across major cohorts.
This helps reinforce the overall message from individual studies: Active Surveillance can be a safe option for appropriately selected men when it is done with careful follow-up.
Summary of the Evidence and Guidelines Supporting Active Surveillance
Overall picture
Taken together, the guidelines and long-term studies point in the same direction: for many men with low-risk localized prostate cancer, Active Surveillance is a well-supported and evidence-based option.
The strongest support is for low-risk disease. Some guidelines also support Active Surveillance for carefully selected men with favorable intermediate-risk disease.
A steady way to think about it
Active Surveillance is not the right fit for every man, and it is not risk-free. But the evidence shows that, for many men with low-risk prostate cancer, it offers a way to stay closely monitored while delaying or avoiding treatment unless it becomes necessary.
Core references
- National Comprehensive Cancer Network (NCCN) patient guideline
https://www.nccn.org/patients/guidelines/content/PDF/prostate-early-patient.pdf - American Urological Association / American Society for Radiation Oncology (AUA / ASTRO) guideline
https://www.auanet.org/guidelines-and-quality/guidelines/clinically-localized-prostate-cancer-aua/astro-guideline-2022 - Cancer Care Ontario guideline
https://www.cancercareontario.ca/en/file/70621/download?token=N9tF85VE - European Association of Urology (EAU) guideline
https://uroweb.org/guidelines/prostate-cancer/chapter/treatment - National Institute for Health and Care Excellence (NICE) guideline
https://www.nice.org.uk/guidance/ng131/chapter/recommendations - European Society for Medical Oncology (ESMO) guideline
https://www.esmo.org/guidelines/living-guidelines/esmo-living-guideline-local-and-locoregional-prostate-cancer/management-of-localised-prostate-cancer/management-of-localised-disease-watchful-waiting-and-active-surveillance - Cancer Council Australia optimal care pathway
https://www.cancer.org.au/assets/pdf/ocp/prostate-cancer-2nd-edition - ProtecT trial
Hamdy FC et al. Fifteen-Year Outcomes after Monitoring, Surgery, or Radiotherapy for Prostate Cancer.
https://pubmed.ncbi.nlm.nih.gov/36912538/ - Johns Hopkins Grade Group 1 cohort
Tosoian JJ et al. Active Surveillance of Grade Group 1 Prostate Cancer: Long-term Outcomes from a Large Prospective Cohort.
https://pubmed.ncbi.nlm.nih.gov/31918957/ - Sunnybrook / Toronto cohort
Klotz L et al. Long-term follow-up of a large active surveillance cohort of patients with prostate cancer.
https://pubmed.ncbi.nlm.nih.gov/25512465/ - PASS multicentre cohort
Newcomb LF et al. Long-Term Outcomes in Patients Using Protocol-Directed Active Surveillance for Prostate Cancer.
https://pubmed.ncbi.nlm.nih.gov/38814624/ - PRIAS international study
Bokhorst LP et al. Long-term outcomes of active surveillance for prostate cancer: The PRIAS study.
https://pubmed.ncbi.nlm.nih.gov/27329565/ - Memorial Sloan Kettering cohort
Ehdaie B et al. Long-term outcomes of active surveillance for prostate cancer at a large tertiary center.
https://pubmed.ncbi.nlm.nih.gov/31868556/ - Narrative review of Active Surveillance cohorts
https://pmc.ncbi.nlm.nih.gov/articles/PMC8261451/
Further reading
- American Cancer Society. Observation or Active Surveillance for Prostate Cancer.
https://www.cancer.org/cancer/types/prostate-cancer/treating/watchful-waiting.html - National Cancer Institute. Active Surveillance for Low-Risk Prostate Cancer Continues to Rise.
https://www.cancer.gov/news-events/cancer-currents-blog/2022/prostate-cancer-active-surveillance-increasing - Fred Hutch Cancer Center. Active surveillance shown to be an effective management strategy for prostate cancer patients.
https://www.fredhutch.org/en/news/releases/2024/05/active-surveillance-shown-to-be-an-effective-management-strategy.html