Beyond One-Size-Fits-All Active Surveillance for Low-Risk Prostate Cancer: Risk-Adapted Follow-Up, De-Escalation...

Area of Science:

• Oncology
• Urology
• Cancer Management

Background:

• Historically, low-risk prostate cancer (PCa) has been overtreated, leading to significant patient morbidity.
• Contemporary data show a substantial decrease in radical prostatectomies for low-grade PCa, indicating a shift in practice.
• Long-term studies demonstrate the safety of deferring treatment for low-risk PCa, with high cancer-specific survival rates.

Purpose of the Study:

• To review and summarize current evidence supporting conservative management for low-risk prostate cancer.
• To establish a practical, risk-adapted framework for managing patients undergoing active surveillance (AS).
• To compare AS follow-up protocols and explore criteria for de-intensifying surveillance and the role of focal therapy.

Main Methods:

• Comprehensive literature review of contemporary data, long-term studies, and major clinical guidelines.
• Analysis of risk stratification systems and their impact on patient classification.
• Evaluation of outcomes for active surveillance and emerging focal therapy strategies.

Main Results:

• Active surveillance (AS) is now the preferred management for low-risk PCa, supported by major guidelines.
• A decline in surgical overtreatment is evident, with AS demonstrating excellent long-term cancer-specific survival (>95% at 15-25 years).
• Novel risk stratification methods can reclassify more men as low-risk without compromising outcomes; focal therapy shows potential but requires more evidence.

Conclusions:

• The management paradigm for low-risk PCa has shifted towards conservatism, with AS as the established standard of care.
• Refining risk stratification and evaluating focal therapy are crucial for optimizing individualized care and minimizing harm.
• This review provides a framework for risk-adapted AS, including de-intensification criteria and the role of focal therapy.