A quiet revolution in prostate cancer care has reached an extraordinary scale among U.S. veterans. In 2024, 93% of veterans diagnosed with low-risk prostate cancer chose active surveillance rather than immediate surgery or radiation, according to a large study led by researchers at the University of California, San Francisco, and the San Francisco VA Health Care System. The figure marks a dramatic rise from 27% in 2005, when active surveillance was still viewed by many patients and clinicians as an uncertain alternative to treatment. The same shift was observed among veterans with favorable intermediate-risk disease, a category involving somewhat more concerning tumors. In that group, surveillance increased from 14% in 2005 to 61% in 2024. The findings, published in JAMA on August 13, suggest that monitoring rather than immediately removing or irradiating a tumor has become the dominant strategy for men whose disease is unlikely to threaten their lives in the near term.
The study followed more than 73,000 veterans receiving care through the U.S. Department of Veterans Affairs, one of the largest integrated health systems in the country. Researchers from UCSF, the San Francisco VA, VA Boston Healthcare System, Harvard Medical School, and Boston University School of Medicine analyzed treatment patterns over nearly two decades. Their work was conducted through PROFOUND-VET, a Veterans Affairs research initiative designed to develop and evaluate cancer-care guidelines. Rather than asking whether one individual treatment was superior in a randomized clinical trial, the investigators examined how real-world clinical practice changed across the VA system. The results reveal a striking transformation: a diagnosis that once commonly triggered immediate intervention is increasingly being managed through careful observation, repeated testing, and treatment only when biological evidence suggests that the cancer is becoming more dangerous.
Active surveillance is not the same as ignoring cancer. It is a structured monitoring program intended to separate tumors that remain biologically indolent from those that show signs of progression. Patients commonly undergo prostate-specific antigen, or PSA, blood testing every three to six months. PSA is a protein produced by prostate tissue, and changes in its concentration can provide clues about tumor activity, although the marker is not perfectly specific for cancer. Physicians may also perform digital rectal examinations, magnetic resonance imaging, and repeat prostate biopsies at longer intervals. MRI can reveal changes in the size, shape, or cellular characteristics of a suspicious lesion, while biopsy allows pathologists to reassess the tumor’s microscopic grade. If tests show that the cancer has grown, become more aggressive, or acquired other warning signs, the patient can move to definitive treatment with surgery or radiation.
The biological logic behind surveillance is rooted in the diversity of prostate tumors. Some prostate cancers grow slowly for many years, remain confined to the gland, and never cause symptoms or shorten a person’s life. Others are aggressive from the outset and can invade nearby tissues or spread to distant organs. Conventional screening can detect both types, but a positive diagnosis does not automatically reveal which biological path a tumor will follow. Treating every detected tumor as an immediate threat can therefore expose patients to the harms of therapy without providing a meaningful survival benefit. Prostate surgery may damage nerves and muscles involved in erections and urinary control, while radiation can contribute to urinary, bowel, and sexual problems. Active surveillance seeks to preserve those functions while retaining the option of curative treatment if the cancer’s behavior changes.
The rising use of surveillance reflects evidence accumulated over several decades, including research associated with UCSF that helped establish the approach as a national standard for low-risk disease. Long-term studies have found that carefully selected patients managed with surveillance can experience survival outcomes similar to those of patients treated immediately, particularly when the cancer has a very low likelihood of spreading. The comparison is not simply between treatment and no treatment. It is between immediate treatment for everyone and a risk-adapted strategy in which low-risk patients are monitored and higher-risk biological features prompt intervention. This distinction is crucial because the goal is not to avoid treatment at all costs; it is to ensure that treatment is directed toward tumors capable of causing harm.
The new VA data also illuminate how health-system design can influence cancer care. Grace Lee, a UCSF urology resident and physician at the San Francisco VA, said the surveillance approach may be more common in the VA than in outside clinical practices because the system can track quality measures, provide feedback to physicians, and maintain long-term continuity of care. Those features are particularly important for active surveillance, which depends on reliable follow-up rather than a single decision made at diagnosis. A patient must receive scheduled PSA tests, imaging, and biopsies, and clinicians must recognize when results warrant a change in strategy. In a fragmented healthcare environment, missed appointments, incomplete records, or changes in insurance and providers can make that process more difficult. An integrated system can create reminders, standardize protocols, and monitor whether patients remain safely within the surveillance pathway.
The study’s findings also carry a message about the consequences of prostate cancer screening. Screening can save lives by identifying aggressive cancers before they spread, when surgery or radiation may be more effective. Yet the same process can uncover tumors that would never have become clinically important. This phenomenon, known as overdiagnosis, occurs when a screening program detects a disease that would not have caused symptoms or death during the patient’s lifetime. Overtreatment follows when that diagnosis is treated as an unavoidable medical emergency. Matthew Cooperberg, senior author of the study and the Helen Diller Family Chair in the UCSF Department of Urology, said screening detects many slow-growing prostate tumors that should rarely require immediate treatment. He noted that some experts increasingly question whether the least dangerous lesions should even be labeled “cancer,” because the word can produce fear and push patients toward unnecessary procedures.
That concern does not mean surveillance is appropriate for every man with prostate cancer. Risk classification incorporates the tumor’s grade, the amount of cancer found in biopsy samples, PSA levels, clinical examination, imaging findings, and other factors. Low-risk disease generally has features associated with limited growth and a low probability of metastasis. Favorable intermediate-risk disease occupies a more complicated middle ground: some tumors in this group can be monitored safely, while others may benefit from treatment depending on the patient’s age, health, tumor volume, genetic features, and preferences. Surveillance also requires psychological readiness. Repeated tests can create anxiety, and a rising PSA does not always mean that cancer has become more aggressive. Inflammation, prostate enlargement, infection, and testing variability can all affect the marker. For that reason, treatment decisions usually depend on a pattern of evidence rather than a single abnormal result.
The researchers’ conclusions are based on observational data from veterans receiving care in the VA system, so the results do not prove that the health system alone caused the increase or that identical rates would occur in every population. Veterans may differ from privately insured patients in age, medical history, access to specialists, and the way their cancers are detected and classified. The study nevertheless provides a powerful snapshot of changing medical practice at national scale. It shows that active surveillance has moved from a pioneering concept to a mainstream response to low-risk prostate cancer, with adoption accelerating as clinical evidence, monitoring technology, and physician experience have matured. The trend may also reflect better conversations between patients and clinicians about the tradeoff between a possible reduction in cancer risk and the immediate harms of treatment.
For men newly diagnosed with low-risk prostate cancer, the central question is increasingly not “How quickly can the tumor be removed?” but “How likely is this tumor to cause harm, and how confidently can we monitor it?” The VA experience suggests that, when surveillance is organized and follow-up is dependable, most men in this category can avoid or postpone invasive treatment without abandoning cancer care. The approach transforms diagnosis into an ongoing assessment of tumor biology. As screening continues to identify more early-stage disease, the ability to distinguish dangerous cancers from indolent ones will become even more important. The dramatic rise from 27% to 93% among veterans indicates that prostate cancer medicine is entering an era in which restraint, precision, and continuous measurement may protect patients as much as immediate intervention.
Subject of Research: Active surveillance for low-risk and favorable intermediate-risk prostate cancer among U.S. veterans.
News Publication Date: August 13.
Web References: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2026.13471
References: JAMA study by researchers from the University of California, San Francisco; San Francisco VA Health Care System; VA Boston Healthcare System; Harvard Medical School; and Boston University School of Medicine. UCSF researchers Matthew Cooperberg and Grace Lee were quoted in the source material.
Keywords: Prostate cancer, active surveillance, cancer screening, PSA testing, prostate tumors, Veterans Affairs, urology, radiation therapy, prostate surgery, cancer overdiagnosis.
Tags: changes in prostate cancer managementearly prostate cancer treatment optionsimpact of active surveillancelow-risk prostate cancer managementnon-invasive prostate cancer monitoringProstate cancer active surveillanceprostate cancer clinical guidelinesprostate cancer risk stratificationprostate cancer treatment decision-makingprostate cancer treatment in VA healthcareprostate cancer treatment trendsveterans prostate cancer care
