Beyond One-Size-Fits-All Active Surveillance for Low-Risk Prostate Cancer: Risk-Adapted Follow-Up, De-Escalation Pathways, and Focal Therapy as Tailored Strategy

Low-risk prostate cancer (PCa) has historically been overtreated, exposing men to unnecessary morbidity. Emerging evidence supports conservative management of low-risk PCa without immediate radical intervention. Contemporary data show a marked decline in surgical overtreatment, with the proportion of radical prostatectomies yielding only Grade Group 1 cancers falling from 32.4% in 2010 to 7.8% in 2020 in the US SEER registry. Long-term studies confirm that deferring treatment is safe for low-risk disease, with PCa-specific survival exceeding 95% at 15–25 years for cohorts managed with surveillance. Major guidelines now endorse active surveillance (AS) as the preferred management for low-risk PCa. An alternative risk stratification system that expands the low-risk category was shown to reclassify 45–83% more men as low risk without increasing 15-year PCa mortality. Focal therapy has emerged as a potential middle-ground strategy, though evidence is still limited. The paradigm for managing low-risk PCa has shifted toward conservatism, with AS firmly established as the standard of care. Continued efforts to refine risk stratification and evaluate focal therapy are needed to further optimize individualized care, minimize harm, and maintain excellent cancer-specific outcomes for low-risk PCa. This comprehensive review aims to create a practical, risk-adapted framework for managing patients on AS. We will: (i) summarize inclusion criteria and outcomes, (i) compare AS follow-up schedules across major institutions and guidelines, (iii) provide evidence-based criteria to de-intensify surveillance in men with sustained stability and (iv) clarify the role of focal therapy as an intermediate treatment option within the AS continuum.

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Publication Details

Journal
Diagnostics
Published
2026-04-27
DOI
https://doi.org/10.3390/diagnostics16091310
Primary Topic
Prostate Cancer Diagnosis and Treatment
Type
article
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article

Beyond One-Size-Fits-All Active Surveillance for Low-Risk Prostate Cancer: Risk-Adapted Follow-Up, De-Escalation Pathways, and Focal Therapy as Tailored Strategy

Filippo Turri, Paolo Dell’Oglio, Michele Talso, Veronica Mollica et al.
Diagnostics
Prostate Cancer Diagnosis and Treatment
article

Beyond One-Size-Fits-All Active Surveillance for Low-Risk Prostate Cancer: Risk-Adapted Follow-Up, De-Escalation Pathways, and Focal Therapy as Tailored Strategy

Filippo Turri, Paolo Dell’Oglio, Michele Talso, Veronica Mollica, E. De Lorenzis, Savio Domenico Pandolfo, Fabio Zattoni, Lorenzo Bianchi, Andrea Mari, Michele Marchioni, Marco Moschini, Francesco Soria, Riccardo Giuseppe Bertolo, Ugo Giovanni Falagario, Daniele Amparore, Riccardo Campi, Simone Albisinni, Roberto Contieri
article en

Abstract

Low-risk prostate cancer (PCa) has historically been overtreated, exposing men to unnecessary morbidity. Emerging evidence supports conservative management of low-risk PCa without immediate radical intervention. Contemporary data show a marked decline in surgical overtreatment, with the proportion of radical prostatectomies yielding only Grade Group 1 cancers falling from 32.4% in 2010 to 7.8% in 2020 in the US SEER registry. Long-term studies confirm that deferring treatment is safe for low-risk disease, with PCa-specific survival exceeding 95% at 15–25 years for cohorts managed with surveillance. Major guidelines now endorse active surveillance (AS) as the preferred management for low-risk PCa. An alternative risk stratification system that expands the low-risk category was shown to reclassify 45–83% more men as low risk without increasing 15-year PCa mortality. Focal therapy has emerged as a potential middle-ground strategy, though evidence is still limited. The paradigm for managing low-risk PCa has shifted toward conservatism, with AS firmly established as the standard of care. Continued efforts to refine risk stratification and evaluate focal therapy are needed to further optimize individualized care, minimize harm, and maintain excellent cancer-specific outcomes for low-risk PCa. This comprehensive review aims to create a practical, risk-adapted framework for managing patients on AS. We will: (i) summarize inclusion criteria and outcomes, (i) compare AS follow-up schedules across major institutions and guidelines, (iii) provide evidence-based criteria to de-intensify surveillance in men with sustained stability and (iv) clarify the role of focal therapy as an intermediate treatment option within the AS continuum.

DiagnosticsVol. 16(9)
University of Foggia (IT), University of Rome Tor Vergata (IT), University of Verona (IT), University of Padua (IT), Vita-Salute San Raffaele University (IT), University of Milan (IT), University of L'Aquila (IT), Agostino Gemelli University Polyclinic (IT), Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico (IT), Karolinska Institutet (SE), Ospedale Maggiore (IT), Azienda Socio Sanitaria Territoriale Grande Ospedale Metropolitano Niguarda (IT), Saint Camillus International University of Health and Medical Sciences (IT), Azienda Ospedaliero Universitaria San Giovanni Battista (IT), Azienda Ospedaliero-Universitaria Careggi (IT), Azienda USL di Bologna (IT), Policlinico Abano Terme (IT), Istituto Nazionale Tumori IRCCS "Fondazione G. Pascale" (IT), Candiolo Cancer Institute (IT), ASST Fatebenefratelli Sacco (IT), University of Florence (IT), University of Turin (IT), University of Naples Federico II (IT)
Reduced inequalities
Openalex Percentile: Top 9%
Prostate Cancer Diagnosis and Treatment
DOIOpen Access PDFOpenAlex
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