Long-Term Outcomes with Structured Active Surveillance of Low-Grade Prostate Cancer

A randomized trial has documented favorable long-term outcomes for patients with low-grade prostate cancer who initially undergo active surveillance rather than definitive treatment (NEJM JW Gen Med Apr 1 2023 and N Engl J Med 2023; 388:1547). However, in real-world practice, adherence to a structured protocol is not always optimal. In this prospective observational study, researchers at 10 U.S. and Canadian academic medical centers enrolled 2155 men (median age, 63) who were managed with active surveillance. About 85% of the cases were classified as low or very low risk, and 15% were favorable intermediate risk. Protocol-directed follow-up involved PSA testing every 3 to 6 months, confirmatory biopsies at 6 to 12 months after diagnosis, and subsequent biopsies every 2 years after diagnosis. Adherence to the protocol was roughly 90%.

At a median follow-up of 7.2 years, about half of patients maintained their low-grade classification and received no treatment. Cancer grade was reclassified in 43% of participants, and 49% underwent radiotherapy or surgery. Progression to metastatic cancer occurred in 21 patients (1%), and 3 patients died of prostate cancer.