Active Surveillance for Low-Risk Prostate Cancer: Long-Term Oncologic Outcomes from Prospective Cohorts
Keywords:
Prostatic neoplasms; watchful waiting; neoplasm grading; disease progression; survival analysisAbstract
Introduction: Active surveillance (AS) aims to avoid overtreatment of low-risk prostate cancer. However, long-term (>10 years) outcomes are still emerging. This review consolidates data from large prospective AS cohorts on metastasis and cancer-specific mortality.
Methods: A systematic search of MEDLINE, Embase, and PROSPERO registries (2000–2024) identified prospective cohort studies of AS for low-risk prostate cancer (PSA ≤10, Gleason 3+3, cT1c-T2a) with minimum 10-year follow-up. Primary outcome: metastasis-free survival (MFS) and prostate cancer-specific mortality (PCSM).
Results: Five cohorts (n=4,527) reported 10–15 year outcomes. Overall, 41% (range 36–48%) received delayed treatment (median time to treatment 4.8 years). Metastasis-free survival at 10 years was 96% (95%CI 94–98%). PCSM was 1.2% at 10 years and 2.8% at 15 years. Grade reclassification to Gleason 4+3 occurred in 13% of men by 10 years. PSA density >0.15 was the strongest predictor of progression.
Discussion: AS provides excellent long-term cancer control for carefully selected men. Risk of metastasis and death is low but not zero. Older studies used less rigorous protocols (annual biopsy vs. MRI). Racial/ethnic minorities are underrepresented.
Conclusions: Active surveillance is a safe management strategy for low-risk prostate cancer with <3% cancer-specific mortality at 15 years. Strict monitoring with MRI and targeted biopsy is essential.
