Active surveillance in intermediate-risk prostate cancer

Objectives Active surveillance (AS), now the standard of care for most men with favourable-risk prostate cancer, is appealing for selected men with 'favourable' intermediate-risk prostate cancer. Methods This is a review of the indications for conservative management in this population, the outcomes reported in prospective series, and the use of molecular biomarkers and imaging to identify optimal candidates. Results Candidates are those patients who are categorized as having intermediate-risk disease either because of a prostate-specific antigen level between 10 and 20 ng/mL, or by virtue of having Grade Group 2 disease, with a small percentage of Gleason 4 pattern, and a negative magnetic resonance imaging result or negative targeted biopsy of a region of interest. Confirmation with a favourable score on a tissue-based genetic assay can provide further reassurance. A subset of patients with intermediate-risk disease has indolent disease that may benefit from AS; at the same time, some patients with intermediate-risk disease have an aggressive clinical course that requires early definitive therapy. This heterogeneity is not adequately captured with traditional histopathological staging. Clinical, genomic and radiological biomarkers are the key to appropriate risk stratification and patient selection. Conclusions The benefits of AS make it an appealing option for selected patients with intermediate-risk disease.