Active surveillance for intermediate-risk prostate cancer: a systematic review and pooled analysis

Active surveillance (AS) is the preferred management for individuals with low-risk prostate cancer (PCa), but its role in intermediate-risk (IR) disease remains underreported. Given growing interest and published data, we performed an updated systematic review and meta-analysis to evaluate AS outcomes in selected patients with Gleason Grade Group (GG) 1-2 IR PCa.

A systematic review was conducted according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines (PROSPERO CRD420251138532). PubMed/MEDLINE, Embase, and Web of Science databases were searched for studies published up to September 2025 reporting outcomes of AS in IR PCa. Primary outcomes were AS discontinuation-free survival and GG ≥3 upgrade-free survival.

In total, 18 studies, including 3783 selected patients with IR PCa, were analyzed. Pooled AS discontinuation-free survival rates were 70% (95% confidence interval [CI] 62-78) at 3 years, 63% (95% CI 58-68) at 5 years, and 53% (95% CI 38-67) at 10 years. In analyses restricted to GG 2 cohorts, corresponding pooled estimates were 72% at 3 years, 56% at 5 years, and 40% at 10 years. GG ≥3 upgrade-free survival was 84% (95% CI 76-92) at 3 years and 78% (95% CI 65-91) at 5 years in all cohorts and 92% (95% CI 86-98) and 87% (95% CI 78-95) at 3 and 5 years in cohorts screened using multiparametric magnetic resonance imaging. No significant difference in AS discontinuation was observed between biopsy GG 1 and 2 (hazard ratio 1.08; 95% CI 0.86-1.35). Limitations include moderate risk of bias and heterogeneity across AS protocols.

Although long-term data are lacking, particularly regarding robust oncological outcomes, growing evidence suggests that AS appears oncologically safe in well-selected patients. Magnetic resonance imaging will play a key role in the appropriate selection and follow-up of patients.