Table 1.
International guidelines for active surveillance
| Risk stratification | Inclusion | AS protocol – Year 1 | AS protocol – Year 2+ | Switch to radical treatment criteria | |
|---|---|---|---|---|---|
| NICE 22 |
PSA <10 ng/mL AND Gleason score ≤6 AND Clinical stage T1–T2a |
Low‐risk Consider in intermediate‐risk, localized tumours. |
PSA every 3–4 months Monitor PSA kinetics throughout AS DRE every 6–12 months Repeat TRUS biopsy at 12 months |
PSA every 3–6 months Monitor PSA kinetics throughout AS DRE every 6–12 months |
Evidence of progression, in light of patient preferences, comorbidities and life expectancy |
| BAUS 29 |
PSA <10 ng/mL Gleason score ≤6 Clinical T‐stage T1–T2 <50% positive biopsy cores |
Low‐risk and low‐volume intermediate‐risk |
PSA, MRI ± TRUS biopsy at 3‐month review Further review after 6–12 months Repeat mpMRI at 12 months |
Regular PSA blood test Review every 12 months Repeat mpMRI and biopsy every 2–4 years |
Re‐investigate or progress to radical treatment if: significant PSA rise; changes on DRE or MRI; change in patient preference; increased tumour volume or grade on repeat biopsy |
| AUA [30] |
PSA <10 ng/mL Grade group 1 (Gleason ≤6) Clinical stage T1–T2a |
Low‐risk Intermediate‐ (favourable) risk |
PSA every 3 months DRE at review Repeat TRUS biopsy within 2 years Consider mpMRI |
PSA every 3–6 months DRE at review Surveillance biopsies |
Adverse reclassification Growth of lesion on mpMRI Increased PSA density |
| National Comprehensive Cancer Network [31] |
PSA <10 ng/mL Gleason score ≤6 Clinical stage T1–T2a |
Low‐risk |
PSA >6 monthly DRE >12 monthly Repeat TRUS biopsy >12 monthly Consider mpMRI if signs of progression |
PSA >6 monthly DRE >12 monthly Repeat biopsy >12 monthly Consider mpMRI if signs of progression |
Changes on repeat biopsy; Gleason score 4 or 5 Increased number of positive cores Increased tumour length in core |
| Cancer Care Ontario [32] | Low‐risk |
PSA every 3–6 months DRE every 12 months TRUS biopsy within 6–12 months |
PSA every 3–6 months DRE every 12 months Serial biopsy every 3–5 years |
Consider if repeat biopsy shows; Gleason score >6 Significant increase in Gleason score 6 volume |
|
| Canadian Urological Association23 |
PSA <10 ng/mL Gleason score ≤6 Clinical stage ≤2a |
Low‐risk. Consider in intermediate‐risk, localized tumour |
PSA every 3–6 months DRE every 12 months TRUS biopsy within 6–12 months |
PSA every 3–6 months DRE every 12 months Serial biopsy every 3–5 years |
Consider if repeat biopsy shows; Gleason score >6 Significant increase in Gleason score 6 volume |
| European Association of Urology [33] |
PSA <10 ng/mL Gleason score ≤6 Clinical stage T1–T2a |
Low‐risk | Follow‐up based on PSA, DRE and repeat TRUS biopsy. Optimal interval is unclear. | Follow‐up based on PSA, DRE and repeat biopsy. Optimal interval is unclear. |
No agreement currently. Possible criteria include: change in Gleason score; increased positive cores or lengths of cores; T‐stage increase; PSA changes; change in patient preferences |
| PRIAS [34] |
Clinical stage T1c/T2 PSA ≤10 ng/mL PSA density <0.2 ng/mL per mL 1–2 positive cores Gleason score ≤6 |
Low‐risk |
PSA every 3 months Repeat TRUS biopsy at 12 months |
PSA every 3 months until 2 years, then every 6 months Repeat TRUS biopsies after 4 and 7 years, or annually up to 10 years if PSA doubles |
Three or more positive biopsies and/or Gleason score >6 |
AS, active surveillance; mpMRI, multiparametric MRI; NICE, National Institute for Health and Care Excellence; PRIAS, Prostate Cancer Research International: Active Surveillance.