# Active surveillance

Source: https://onco.cc/technologies/active-surveillance/  
OnCo record `active-surveillance` (Technology). Data CC BY-NC 4.0, attribute "Data from OnCo (onco.cc)"; commercial use needs a licence.

## TL;DR

For low-risk prostate cancer, monitoring with PSA, MRI, and repeat biopsy instead of treating, because most such cancers never cause harm.

## Summary

ProtecT (15-year data, 2023) showed prostate-cancer mortality ~3% regardless of surveillance, surgery, or radiation in PSA-detected disease; ~half of surveillance patients eventually had treatment. Now recommended for essentially all Grade Group 1 and many favourable Grade Group 2 cancers. MRI, PSA density, and genomic classifiers (Decipher, ArteraAI) refine eligibility and triggers.

## Fields

- Kind: Technology
- Status: standard-of-care
- Last checked: 2026-09-06
- Principle: Serial PSA, mpMRI, and biopsy; treatment offered on grade or volume progression.
- Since: 1995
- Strengths: Avoids incontinence and erectile dysfunction of treatment in men who would never be harmed; Level-1 evidence of safety (ProtecT)
- Limitations: Anxiety and adherence; Repeat biopsies; Under-used outside high-income countries

## Notes

- Prostate cancer: NICE NG131 defines active surveillance as part of a curative strategy that keeps a man inside the window of curability, with radical treatment considered for those whose tumours show signs of progressing and for those who would prefer intervention. It is not the same as watchful waiting, which the same guideline defines as a strategy for controlling rather than curing, avoiding surgery and radiation and deferring hormone therapy.
- NICE NG131 (1.3.14, table 2) gives the protocol: PSA every 3 to 4 months through year 1, PSA kinetics monitored throughout, a digital rectal examination at 12 months, a multiparametric MRI at 12 to 18 months, then PSA every 6 months and an examination every year, with MRI or repeat biopsy whenever there is concern. NG131 (1.3.8) offers surveillance first for CPG 1, (1.3.9) as one of three choices for CPG 2, (1.3.10) as an option for CPG 3 men who choose not to be treated immediately, and (1.3.11) not at all for CPG 4 and 5.
- In ProtecT, at a median of 15 years, 133 of the 545 men in the active-monitoring group (24.4 percent) were alive with no prostate cancer treatment of any kind; death from prostate cancer had occurred in 17 (3.1 percent) of that group against 12 (2.2 percent) after prostatectomy and 16 (2.9 percent) after radiotherapy, a difference that was not statistically significant.

## Sources

- Wikipedia: https://en.wikipedia.org/wiki/Active_surveillance_of_prostate_cancer
- Wikipedia: https://en.wikipedia.org/wiki/Active_surveillance_of_prostate_cancer
- NICE NG131: prostate cancer, diagnosis and management: https://www.nice.org.uk/guidance/ng131/chapter/Recommendations
- Prostate Cancer UK: localised prostate cancer: https://prostatecanceruk.org/prostate-information-and-support/just-diagnosed/localised-prostate-cancer

## Connected records

- cancers: [Astrocytoma, IDH-mutant (grades 2 to 4)](https://onco.cc/cancers/idh-mutant-astrocytoma/), [Breast cancer (all types)](https://onco.cc/cancers/breast-cancer/), [Chondrosarcoma](https://onco.cc/cancers/chondrosarcoma/), [Chromophobe renal cell carcinoma](https://onco.cc/cancers/chromophobe-rcc/), [Clear cell renal cell carcinoma](https://onco.cc/cancers/clear-cell-rcc/), [Desmoid tumour](https://onco.cc/cancers/desmoid-tumour/), [Ductal carcinoma in situ (DCIS)](https://onco.cc/cancers/ductal-carcinoma-in-situ/), [Epithelioid haemangioendothelioma](https://onco.cc/cancers/epithelioid-haemangioendothelioma/), [Erdheim-Chester disease](https://onco.cc/cancers/erdheim-chester-disease/), [Follicular lymphoma](https://onco.cc/cancers/follicular-lymphoma/), [Germ cell tumours of childhood and adolescence (extracranial and CNS)](https://onco.cc/cancers/paediatric-germ-cell-tumours/), [Hereditary pheochromocytoma and paraganglioma (SDHx, VHL, RET, NF1, MAX and TMEM127)](https://onco.cc/cancers/hereditary-ppgl/), [Langerhans cell histiocytosis (LCH)](https://onco.cc/cancers/langerhans-cell-histiocytosis/), [Localised prostate cancer, intermediate risk](https://onco.cc/cancers/prostate-intermediate-risk/), [Localised prostate cancer, very low and low risk](https://onco.cc/cancers/prostate-low-risk/), [Low-risk neuroblastoma (INRG very low and low risk, including stage MS)](https://onco.cc/cancers/neuroblastoma-low-risk/), [Meningioma](https://onco.cc/cancers/meningioma/), [Metastatic pheochromocytoma and paraganglioma](https://onco.cc/cancers/metastatic-ppgl/), [Nodular lymphocyte-predominant Hodgkin lymphoma (nodular lymphocyte-predominant B-cell lymphoma)](https://onco.cc/cancers/nodular-lymphocyte-predominant-hodgkin-lymphoma/), [Non-seminomatous germ cell tumour](https://onco.cc/cancers/non-seminoma/), [Oesophageal cancer](https://onco.cc/cancers/esophageal/), [Oligodendroglioma, IDH-mutant and 1p/19q-codeleted](https://onco.cc/cancers/oligodendroglioma/), [Papillary renal cell carcinoma](https://onco.cc/cancers/papillary-rcc/), [Papillary thyroid cancer](https://onco.cc/cancers/papillary-thyroid-cancer/), [Peritoneal mesothelioma](https://onco.cc/cancers/peritoneal-mesothelioma/), [Perivascular epithelioid cell tumour (PEComa)](https://onco.cc/cancers/pecoma/), [Prostate cancer](https://onco.cc/cancers/prostate/), [Rosai-Dorfman-Destombes disease](https://onco.cc/cancers/rosai-dorfman-disease/), [Seminoma](https://onco.cc/cancers/seminoma/), [Single-system Langerhans cell histiocytosis (bone, skin or one other organ)](https://onco.cc/cancers/lch-single-system/), [Spinal cord tumours (intramedullary and intradural)](https://onco.cc/cancers/spinal-cord-tumours/), [Testicular germ cell tumours](https://onco.cc/cancers/testicular/), [Vascular tumours (angiosarcoma, epithelioid haemangioendothelioma, kaposiform haemangioendothelioma)](https://onco.cc/cancers/vascular-tumours/), [Vestibular schwannoma (acoustic neuroma)](https://onco.cc/cancers/vestibular-schwannoma/), [Waldenström macroglobulinaemia](https://onco.cc/cancers/waldenstrom/), [Wilms tumour (nephroblastoma)](https://onco.cc/cancers/wilms-tumor/)
- fronts: [Diagnostics & Biomarkers](https://onco.cc/fronts/diagnostics/), [Surgery & Interventional](https://onco.cc/fronts/surgery/)
- technologies: [Active surveillance of papillary microcarcinoma](https://onco.cc/technologies/active-surveillance-thyroid/), [Multiparametric prostate MRI (PI-RADS)](https://onco.cc/technologies/mp-mri/), [PSA and MRI-first prostate cancer screening](https://onco.cc/technologies/prostate-screening-psa-mri/), [Tumour volume doubling time](https://onco.cc/technologies/tumour-doubling-time/)
- drugs: [ArteraAI Prostate](https://onco.cc/drugs/artera-ai-prostate/), [Decipher Prostate](https://onco.cc/drugs/decipher-prostate/), [Oncotype DX Genomic Prostate Score](https://onco.cc/drugs/oncotype-dx-gps/), [Padeliporfin](https://onco.cc/drugs/padeliporfin/), [Prolaris](https://onco.cc/drugs/prolaris/)
- trials: [AGCT1531](https://onco.cc/trials/agct1531/), [ANCHOR](https://onco.cc/trials/anchor/), [CALGB 9343](https://onco.cc/trials/calgb-9343/), [CLL12](https://onco.cc/trials/cll12/), [LUMINA](https://onco.cc/trials/lumina/), [PIVOT (Prostate Cancer Intervention Versus Observation Trial)](https://onco.cc/trials/pivot/), [PRIME II](https://onco.cc/trials/prime-ii/), [ProtecT](https://onco.cc/trials/protect/), [SANO](https://onco.cc/trials/sano/)
- terms: [Active surveillance and observation](https://onco.cc/terms/active-surveillance-term/), [Choosing treatment for localised prostate cancer: what each option costs](https://onco.cc/terms/prostate-treatment-choice-localised/), [Ductal carcinoma in situ (DCIS)](https://onco.cc/terms/dcis/), [Focal and tissue-preserving treatment of prostate cancer](https://onco.cc/terms/prostate-focal-therapy/), [Gleason score / Grade Group](https://onco.cc/terms/gleason-grade-group/), [Nephrectomy](https://onco.cc/terms/nephrectomy/), [Overdiagnosis](https://onco.cc/terms/overdiagnosis/), [Overtreatment](https://onco.cc/terms/overtreatment/), [PI-RADS (Prostate Imaging Reporting and Data System)](https://onco.cc/terms/pi-rads/), [Radical prostatectomy](https://onco.cc/terms/prostatectomy/), [Smouldering myeloma / MGUS](https://onco.cc/terms/smoldering-myeloma/), [Thyroidectomy](https://onco.cc/terms/thyroidectomy/), [Watchful waiting, and how it differs from active surveillance](https://onco.cc/terms/watchful-waiting/)
- ideas: [Organ preservation as the default after complete response in oesophageal cancer](https://onco.cc/ideas/idea-organ-preservation-esophageal/), [Publish a per-lesion miss rate for every prostate MRI service before it is allowed to guide focal treatment](https://onco.cc/ideas/idea-prostate-per-lesion-mri-audit-before-focal-treatment/)
- key papers: [Overdiagnosis and overtreatment of prostate cancer](https://onco.cc/key-papers/paper-loeb-overdiagnosis-overtreatment-prostate-eur-urol-2014/), [PIVOT: follow-up of prostatectomy versus observation for early prostate cancer](https://onco.cc/key-papers/paper-wilt-pivot-prostatectomy-observation-nejm-2017/)
- bottlenecks: [Overdiagnosis and false alarms](https://onco.cc/bottlenecks/b-overdiagnosis/)
- companies: [MDxHealth](https://onco.cc/companies/mdxhealth/)

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