Active surveillance use for low-risk prostate cancer reaches 93% in VA System

Active surveillance became the initial management approach for 93% of veterans diagnosed with low-risk prostate cancer in 2024, up from 27% in 2005, according to a large retrospective cohort study published in JAMA.¹

The study also found increasing use of surveillance among veterans with favorable intermediate-risk disease, although substantial variation persisted across Veterans Affairs (VA) facilities. The findings provide evidence of a marked shift away from immediate definitive treatment within the VA health care system, while also highlighting differences in surveillance use according to disease characteristics and patient demographics.

“Prostate cancer screening saves thousands of lives by finding aggressive cancers early, but it also detects many slow-growing cancers that do not spread, and should not be treated except in rare situations,” said senior author Matthew R. Cooperberg, MD, MPH, of the University of California, San Francisco (UCSF), in a news release on the findings.²

“Many experts are recommending that we not even call these ‘cancers,’ ” Cooperberg added. “Patients with early disease who say they prefer treatment may need better counseling.”

Surveillance use increased across favorable-risk groups

The study was conducted by investigators from UCSF, the San Francisco VA Health Care System, and other VA institutions through the PROFOUND-VET research initiative. Investigators used national VA data to examine management patterns among patients diagnosed from 2005 through 2024.

Patients were classified as receiving active surveillance or watchful waiting if they did not receive treatment within 15 months of diagnostic biopsy and met additional criteria based on prostate-specific antigen (PSA) testing or confirmatory biopsy. The available electronic health record data could not consistently distinguish active surveillance from watchful waiting.

The median age of the cohort was 65 years (IQR, 60 to 69 years). Among 73,042 veterans diagnosed with National Comprehensive Cancer Network (NCCN)–defined low-risk or favorable intermediate-risk prostate cancer between 2005 and 2024, 38,130 were initially managed with active surveillance or watchful waiting.

Among patients with low-risk disease, active surveillance use increased from 27% in 2005 to 93% in 2024. Among those with favorable intermediate-risk disease, use increased from 14% to 61% over the same period.

Surveillance also increased among specific favorable intermediate-risk subgroups. For patients with a PSA level below 10 ng/mL and Grade Group 2 disease in less than 50% of biopsy cores, surveillance increased from 11% to 55%. Among patients with Grade Group 1 disease and a PSA level of 10 to 20 ng/mL, use increased from 27% to 88%.

On multivariable analysis, older age (OR, 1.43 per decade; 95% CI, 1.39 to 1.47; P < .001) and more recent year of diagnosis (OR, 1.21 per year; 95% CI, 1.21 to 1.22; P < .001) were associated with greater odds of surveillance. Conversely, Grade Group 2 disease (OR, 0.13; 95% CI, 0.12 to 0.13; P < .001), a greater proportion of positive biopsy cores (OR, 0.88 per decile; 95% CI, 0.87 to 0.89; P < .001), Black or African American race (OR, 0.95 vs White; 95% CI, 0.90 to 0.99; P < .001), Hispanic or Latino ethnicity (OR, 0.85 vs non-Hispanic; 95% CI, 0.76 to 0.95; P = .003), and higher Area Deprivation Index scores (OR, 0.97 per quartile; 95% CI, 0.95 to 0.99) were associated with lower odds of surveillance. Travel distance to a VA facility was not associated with surveillance use.

The authors also reported variability among individual VA facilities. Overall surveillance rates ranged from 23% to 93%, although variation narrowed among patients with Grade Group 1 disease diagnosed between 2015 and 2024, with rates ranging from 60% to 100% at all but 1 facility at 26%.

Active surveillance has become standard for low-risk disease

The increasing use of surveillance reflects a broader change in the management of localized prostate cancer. The American Urological Association and American Society for Radiation Oncology recommend active surveillance as the preferred management option for patients with low-risk prostate cancer and recommend discussing active surveillance, radiation therapy, and radical prostatectomy with appropriately selected patients with favorable intermediate-risk disease.³

Related: The AUA Clinically Localized Prostate Cancer guideline: FAQs for urologists

The rationale for surveillance is rooted in the relatively favorable natural history of low-risk prostate cancer and the potential harms associated with definitive treatment. Long-term randomized data from the ProtecT trial showed that prostate cancer-specific mortality remained low after 15 years among men with localized prostate cancer assigned to active monitoring, prostatectomy, or radiotherapy, although active monitoring was associated with higher rates of metastatic disease and clinical progression.⁴ In the trial, prostate cancer-specific mortality occurred in 3.1% of men assigned to active monitoring, compared with 2.2% after prostatectomy and 2.9% after radiotherapy (P = .53 for the overall comparison).

The current findings from the VA system reflect growing adoption of active surveillance in this setting, demonstrating higher rates of surveillance than those reported among US community-based practices or in other US contexts to date.

Lead author Grace Lee, MD, a fifth-year resident physician in the UCSF Department of Urology, who also practices at the San Francisco VA Health Care System, noted that a surveillance approach is more likely in the VA system than in outside clinical practices.

She explained, “The VA is an integrated health care system that has robust practices for tracking quality of care and providing feedback to physicians, and facilitates long-term continuity of patient care.”²

The authors acknowledge several limitations of the current analysis, including the reliance on potentially incomplete electronic health record data, particularly with respect to stage, the inability to distinguish between active surveillance and watchful waiting, and the use of criteria that do not exactly align with NCCN risk groups.

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