Fewer low-risk prostate cancers treated as active surveillance becomes the norm

An analysis of United States cancer registry and health system data shows a broad shift away from treating slow-growing, localized prostate cancer, with most patients now diagnosed with low-risk disease forgoing immediate radiation or surgery. The study, published online in CANCER, a peer-reviewed journal of the American Cancer Society, documents how concerns about overdiagnosis and overtreatment have reshaped both diagnosis and management of the disease since 2010. During the 2010s, recommendations supporting prostate-specific antigen (PSA)–based screening wavered as clinicians and guideline writers grew increasingly concerned that many men were being diagnosed with, and treated for, localized cancers that posed no threat to their lives.

In response, clinical guidelines came to support active surveillance as the preferred approach for low-risk prostate cancer rather than immediate intervention. To assess whether this shift in guidance translated into changed practice at the population level, investigators analyzed localized prostate cancer cases across three large United States data sources: the Surveillance, Epidemiology, and End Results (SEER) program covering 2010 through 2023, the Veterans Affairs (VA) health system covering 2010 through 2024, and the Michigan Radiation Oncology Quality Consortium (MROQC) covering 2021 through 2025. Together, these sources allowed the team to track both how often low-risk cancer was diagnosed and how often it was treated with radiation or prostate removal.

The findings show two converging trends. First, low-risk prostate cancer has become less common at the time of diagnosis. In SEER, the proportion of localized prostate cancers classified as low-risk at diagnosis declined from 28.8% to 24.0% over the study period, while in the VA it fell from 32.3% to 21.9%.

The researchers suggest this moderate decline likely reflects increased use of magnetic resonance imaging in screening. Second, and more strikingly, patients diagnosed with low-risk cancer increasingly avoided immediate treatment altogether. Among men diagnosed with low-risk disease in SEER, the proportion receiving neither radiation nor prostate removal rose from 33.6% to 83.4% by 2023.

In the VA population, that figure climbed from 51.6% to 96.3% by 2024, meaning nearly all veterans with low-risk prostate cancer were managed without immediate definitive treatment. The treatment side of the equation shows the same pattern. Among 207,196 patients who received radiation therapy for localized prostate cancer, the proportion with low-risk disease fell from 33.7% to 6.5% in SEER and from 22.9% to 2.0% in the VA.

In the more recent MROQC cohort, the proportion of irradiated patients with low-risk disease remained low, ranging from 2.8% to 4.2% between 2021 and 2025. “These data reflect broad changes in how prostate cancer is diagnosed and managed in the United States,” said lead author Steven M. Monda, MD, MSCI, of the University of Michigan. “We are seeing a moderate decline in the amount of low-risk prostate cancer being diagnosed, likely reflecting more magnetic resonance imaging use in screening. Moreso however, we are seeing that most of the low-risk prostate cancer is now being appropriately observed and not treated. This is a big win for patients because it means patients are avoiding the harms of unnecessary treatment for cancers that are unlikely to ever affect them.”

The scale of the change is notable given how contested PSA screening became over the same period. Concerns about overdiagnosis and overtreatment had hindered screening in the recent past, and the new analysis indicates that the resulting recommendations for active surveillance have been adopted widely across both SEER and VA settings, transforming the default management of low-risk disease from intervention to observation.

As with any observational analysis of registry and health system data, the study describes population-level trends rather than outcomes of a randomized comparison, and the three data sources cover overlapping but not identical time windows. Even so, the consistency of the patterns across SEER, the VA, and the Michigan quality consortium suggests that the move away from treating low-risk prostate cancer is broad and sustained. For patients, the practical implication is that a low-risk prostate cancer diagnosis today is far less likely to lead to radiation or surgery than it was a decade and a half ago.

Subject of Research: Population-level trends in diagnosis and treatment of low-risk localized prostate cancer in the United States

Article Title: How have diagnostic and treatment decisions for prostate cancer changed in recent years?

Article References: How have diagnostic and treatment decisions for prostate cancer changed in recent years?. Original publication (Bibliographic details unavailable.)

Image Credits: AI Generated

DOI: Not provided

Keywords: prostate cancer, active surveillance, PSA screening, overdiagnosis, overtreatment, SEER, Veterans Affairs, radiation therapy, low-risk cancer, CANCER journal, University of Michigan, cancer epidemiology