Active Surveillance in Intermediate-Risk Prostate Cancer

This narrative review analyzed 85 studies (2009–2025) to assess the safety and outcomes of active surveillance (AS) in intermediate-risk prostate cancer, with AS eligibility typically including patients with favorable intermediate-risk features such as low-volume Gleason 3+4 disease, low PSA density , and favorable imaging or genomic profiles.

The evidence shows that AS is increasingly used in carefully selected favorable intermediate-risk patients— especially those with low-volume Gleason 3+4 disease, low PSA density , and favorable imaging or genomic profiles. In this group, 5–10- year metastasis-free survival exceeds 95%, suggesting that AS can safely reduce overtreatment without compromising short- to mid- term oncologic outcomes. However, outcomes are less favorable in patients with unfavorable intermediate-risk disease, such as those with higher-volume Gleason 3+4 or any Gleason 4+3, elevated PSA density , or adverse imaging/genomic features. These patients face higher risks of progression and prostate cancer–specific mortality .

Key limitations across studies include heterogeneous surveillance protocols, inconsistent definitions of favorable intermediate risk, and a lack of randomized controlled trials.

Overall, AS is a viable option for well-selected, favorable intermediate-risk patients. Improved risk stratification using PSA density , multiparametric MRI, and genomic testing enhances patient selection. The review supports guideline recommendations for individualized AS strategies with standardized monitoring and clearly defined triggers for intervention.

Clin Genitourinary Cancer 2025; 23:5.