Active surveillance responds to a problem well identified in this series: the overdiagnosis and overtreatment of prostate cancers which would never have threatened the life or health of the patient. It makes it possible to postpone, or even permanently avoid, invasive treatment in men whose cancer has a very favorable profile.
1. A simple principle: monitor closely rather than treat immediately
Active surveillance consists of postponing curative treatment (surgery or radiotherapy) in time in a man whose cancer is classified at low risk of progression, while monitoring him closely in order to be able to intervene quickly if the disease shows signs of progression. It is not a passive abstention: it is an active and structured strategy, to which the patient must fully adhere.
This is not the same thing as “abstention-surveillance” (watchful waiting), which concerns patients whose life expectancy is limited and for whom no curative treatment is envisaged: active surveillance is aimed at men in good health, with a long life expectancy, in whom curative treatment remains possible at any time if necessary.
2. Who can benefit from active surveillance?
The selection criteria are based on several convergent elements, evaluated during the diagnosis:
| Criterion | Usual threshold | Why |
|---|---|---|
| Gleason score / ISUP group | Gleason 6 (ISUP 1), sometimes 7 (3+4) depending on the teams | Well differentiated cancer, low evolutionary potential |
| PSA rate | Generally < 10 to 15 ng/mL | Consistent with limited tumor volume |
| Clinical stage | T1c or T2a (no or barely palpable) | Localized cancer, small volume |
| Number of positive samples | Limited (1 to 2 biopsies overall) | Low estimated tumor volume |
These criteria have tended to broaden in recent years, as long-term follow-up data have accumulated and been reassuring.
3. The monitoring protocol: rigorous, but not invasive on a daily basis
Active surveillance monitoring combines several examinations at regular intervals: a PSA measurement every 3 to 6 months, an annual digital rectal examination, a repeated prostate MRI, and control biopsies — generally one to one year, then more spaced apart (every 3 to 5 years) if the situation remains stable. Curative treatment is offered at any time if these examinations show an unfavorable development: progression of PSA, worsening of the Gleason score, or visible development on MRI.
4. Reassuring long-term monitoring data
A reference study from Johns Hopkins University, covering the follow-up of more than a thousand men under active surveillance for 15 years, showed a metastasis-free survival rate of 99.4% at 10 and 15 years. Most of the deaths observed in this cohort were not linked to prostate cancer itself. A European follow-up study at 23 years of age, published in 2025, confirms this trend: to date, no data indicates that men followed under active surveillance live shorter than those treated immediately.
⚠️ Medical takeaway
Active surveillance is not a loss of opportunity for patients who meet the inclusion criteria: long-term follow-up data are reassuring on this point.
The patient remains free to exit the active surveillance protocol at any time if they wish, including for psychological reasons — living with untreated cancer can represent a mental burden on do not underestimate.
A reclassification towards curative treatment does not mean a failure of monitoring: on the contrary, it is proof that the monitoring protocol worked by detecting an evolution in time.
Tips to remember:
- ●Active surveillance is not passive abstention: it is an active strategy, structured by a rigorous monitoring protocol, which allows rapid intervention in the event of developments.
- ●A 15-year follow-up study showed a metastasis-free survival rate of 99.4% among men on active surveillance for low-risk cancer.
- ●Reclassification to active treatment during monitoring is not a failure: it is proof that the protocol detected a development in time.
- ●The inclusion criteria for active surveillance have gradually broadened in recent years, as reassuring data has accumulated.
- ●Living with untreated cancer can represent a real psychological burden: it is normal to discuss it openly with your healthcare team, without this calling into question the merits of the strategy.
