When and How Should Active Surveillance for Prostate Cancer be De-Escalated?

Despite widespread adoption of active surveillance (AS) for low-risk prostate cancer, less is known about how or when monitoring should be deintensified. We performed a narrative review of the available evidence and guidelines addressing transitions from active to passive monitoring, including watchful waiting. Increasing age and comorbidity limit quality-adjusted life years gained from curative intervention, although no universal thresholds exist to denote a transition from active monitoring. Despite observational studies indicating that AS intensity decreases over time, the risk of distant progression also increases with age, suggesting an opportunity to improve decision support that incorporates multiple factors when navigating these decisions. PATIENT SUMMARY: We reviewed the available evidence surrounding transitioning from active monitoring to observation. Clinical practice guidelines and research studies support decreasing intensity based on an appreciation of age, other medical problems, and patient preferences.