* the truisms are that most men die with rather than of prostate cancer, if you live long enough almost all men will get a couple of cancer cells in the prostate
Dr. Matthew Cooperberg takes us on a candid journey through Active Surveillance for prostate cancer—starting with its earliest days in the 1990s, through the ups and downs of PSA screening and treatment trends, and into today’s era of MRI, genomic tests, and AI-guided risk assessment.
This presentation is particularly exceptional, delivered as Dr. Cooperberg received ASPI’s Special Advocacy Award for his leadership in shaping patient-focused guidelines, spearheading pivotal cohort studies, and advocating for surveillance in both clinical and policy arenas.
You’ll hear how landmark trials like PIVOT and ProtecT proved that careful monitoring can spare many men the side effects of surgery or radiation, and how ongoing research is refining who needs a biopsy, when to intervene—and even whether we should rethink calling low-grade lesions “cancer” at all. Whether you’re weighing your own options or supporting someone who is, this video offers clear, compassionate insight into where Active Surveillance has been—and where it’s headed next.
CHAPTERS:
0:36 Past
11:30 Present
22:54 Future
About Dr. Matthew Cooperberg
Dr. Cooperberg is a Professor of Urology and Epidemiology at UCSF, where he directs the Active Surveillance Program. A renowned clinician-researcher, he helped pioneer long-term surveillance cohorts at UCSF, Johns Hopkins, and Toronto, and co-leads the Canary Prostate Consortium’s efforts in risk stratification. His work—spanning large community registries, landmark clinical trials, and innovative biomarker studies—has reshaped guidelines worldwide and improved quality of life for countless men with prostate cancer. In recognition of his advocacy for patient-centered care and evidence-driven policy, ASPI honored him with the 2025 Special Advocacy Award.
The Evolution and Future of Active Surveillance in Prostate Cancer
Introduction
Prostate cancer stands as the most commonly diagnosed cancer among men in the U.S., with over 300,000 new cases annually, and is the second leading cause of cancer-related death. Yet, only a fraction of these men—about 35,000 yearly—actually die from the disease. This stark contrast highlights a central truth: most men with prostate cancer die with it, not from it. The challenge has been and continues to be distinguishing who is truly at risk of lethal disease, while sparing the majority from unnecessary harm.
The Impact of PSA Screening
The introduction of PSA (prostate-specific antigen) screening in the 1990s revolutionized prostate cancer detection. By the mid-1990s and 2000s, there was a dramatic rise in prostate cancer diagnoses, primarily due to enhanced detection of previously unnoticed cancers. This widespread screening did deliver a clear public health victory: a sharp reduction in prostate cancer deaths, surpassed only by the drop in lung cancer mortality linked to anti-smoking campaigns. Statistical analyses estimate that at least half the mortality reduction was directly due to PSA screening.
However, this victory came at a cost. The vast majority of prostate cancers detected were low risk—Gleason 3+3 pattern, low grade, low stage. These men often underwent aggressive treatments (surgery, radiation, hormone therapy), leading to a secondary crisis: overtreatment of cancers that would never have become life-threatening.
Overtreatment: A Public Health Crisis
By the 1990s and 2000s, treating nearly every prostate cancer was the norm, regardless of risk level. Data from cancer registries consistently showed that over 50% of diagnosed cancers were low risk, yet almost all received aggressive treatments. Only 8% of men with the lowest risk were managed with active surveillance, and nearly none with intermediate risk qualified.
This overtreatment led to significant side effects—urinary, sexual, and bowel problems—without a survival benefit in low-risk cases. The consequence was mounting discomfort among primary care providers and the 2012 recommendation by the U.S. Preventive Services Task Force (USPSTF) to halt routine PSA screening, causing a decline in diagnoses and a worrying stabilization (and recent increase) in mortality.
The Birth and Growth of Active Surveillance
Reluctance to treat low-risk prostate cancer aggressively inspired pioneers at UCSF, University of Toronto, and Johns Hopkins to develop active surveillance protocols in the early 1990s. These initially academic programs tracked patients carefully, intervening only if cancers showed signs of progression. Early trials like PIVOT and ProtecT confirmed that immediate treatment offered no survival advantage over surveillance for low-risk men, underscoring the safety of this conservative approach.
But uptake was slow. In the community, fewer than 10% of eligible men received surveillance even into the early 2010s. Things changed rapidly after the 2012 USPSTF recommendation, with surveillance rates in registries rising from under 10% to 40% by 2013, and up to 60% today according to large national registries. Yet, variation in practice remains extreme—some urologists never offer surveillance, while others do almost exclusively.
Current Guidelines: Clearer Than Ever
Today, both the American Urological Association (AUA) and the National Comprehensive Cancer Network (NCCN) designate active surveillance as the standard of care for nearly all men with Grade Group 1 (Gleason 3+3) prostate cancer. There's consensus that very low risk, previously defined in the era of six-core non-targeted biopsies, is now obsolete—most cases diagnosed today would not even warrant a biopsy under current risk stratification paradigms.
The debate over terminology continues. Many experts argue that we should no longer label Grade Group 1 lesions as "cancer" due to their indolent nature, advocating for alternative terms like “premalignant” or “atypical.” The psychological burden and insurance impacts of a “cancer” diagnosis remain significant barriers to optimal care.
Personalizing Surveillance Strategies
Effective surveillance in 2025 means tailoring intensity to the individual:
Low-volume, low-risk (Grade 1, low PSA density): For older men or those with shorter life expectancy, watchful waiting is sufficient—no need for repeated biopsies or MRIs.
Fit men with low but not minimal risk: Fewer biopsies, with longer intervals, can be safely considered.
Men with higher volume Grade 1 or marginal Grade 2 disease: Standard surveillance with regular biopsies and imaging remains appropriate.
Higher-risk men: Active treatment is generally recommended, but surveillance is sometimes still offered in borderline cases, emphasizing that deferral—not avoidance—of treatment is the likely outcome.
Importantly, the VA system has emerged as a national leader, with about 80-90% of eligible men managed by surveillance or watchful waiting.
Challenges and Innovations
Despite progress, many men still are not optimally surveilled. Only 25% of men in some networks actually received the minimum recommended follow-up (three PSAs plus a biopsy in two years). Continued efforts are needed to ensure surveillance is genuinely “active.”
Looking forward, advances in MRI, AI for image and pathology interpretation, molecular biomarkers, and more sophisticated risk stratification systems (like the CAPPRA score and dichotomized Gleason grading) promise to sharpen our definition of “low risk” and further reduce unnecessary treatment.
Focal therapy—targeting just the tumor within the prostate—may also expand, helping men who are borderline surveillance candidates avoid or delay more aggressive therapies.
Conclusion
The story of active surveillance in prostate cancer is one of science, policy, and advocacy aligning to spare thousands of men needless suffering. In 2025, active surveillance is the standard of care for nearly all low-risk prostate cancers, with nuanced expansion into some favorable intermediate risk cases. The focus is now on further reducing overtreatment, improving risk assessment, and perhaps reconsidering the very words we use to describe what is often a harmless finding.
Finally, every advancement in this journey is a product of robust, federally funded research. Continued progress in saving lives—and in sparing men from harm—depends on ongoing investment, advocacy, and education. The future for men diagnosed with prostate cancer has never been brighter, so long as we safeguard the research that brought us here.
Dr. Matthew Cooperberg takes us on a candid journey through Active Surveillance for prostate cancer—starting with its earliest days in the 1990s, through the ups and downs of PSA screening and treatment trends, and into today’s era of MRI, genomic tests, and AI-guided risk assessment.
This presentation is particularly exceptional, delivered as Dr. Cooperberg received ASPI’s Special Advocacy Award for his leadership in shaping patient-focused guidelines, spearheading pivotal cohort studies, and advocating for surveillance in both clinical and policy arenas.
You’ll hear how landmark trials like PIVOT and ProtecT proved that careful monitoring can spare many men the side effects of surgery or radiation, and how ongoing research is refining who needs a biopsy, when to intervene—and even whether we should rethink calling low-grade lesions “cancer” at all. Whether you’re weighing your own options or supporting someone who is, this video offers clear, compassionate insight into where Active Surveillance has been—and where it’s headed next.
CHAPTERS:
0:36 Past
11:30 Present
22:54 Future
About Dr. Matthew Cooperberg
Dr. Cooperberg is a Professor of Urology and Epidemiology at UCSF, where he directs the Active Surveillance Program. A renowned clinician-researcher, he helped pioneer long-term surveillance cohorts at UCSF, Johns Hopkins, and Toronto, and co-leads the Canary Prostate Consortium’s efforts in risk stratification. His work—spanning large community registries, landmark clinical trials, and innovative biomarker studies—has reshaped guidelines worldwide and improved quality of life for countless men with prostate cancer. In recognition of his advocacy for patient-centered care and evidence-driven policy, ASPI honored him with the 2025 Special Advocacy Award.
The Evolution and Future of Active Surveillance in Prostate Cancer
Introduction
Prostate cancer stands as the most commonly diagnosed cancer among men in the U.S., with over 300,000 new cases annually, and is the second leading cause of cancer-related death. Yet, only a fraction of these men—about 35,000 yearly—actually die from the disease. This stark contrast highlights a central truth: most men with prostate cancer die with it, not from it. The challenge has been and continues to be distinguishing who is truly at risk of lethal disease, while sparing the majority from unnecessary harm.
The Impact of PSA Screening
The introduction of PSA (prostate-specific antigen) screening in the 1990s revolutionized prostate cancer detection. By the mid-1990s and 2000s, there was a dramatic rise in prostate cancer diagnoses, primarily due to enhanced detection of previously unnoticed cancers. This widespread screening did deliver a clear public health victory: a sharp reduction in prostate cancer deaths, surpassed only by the drop in lung cancer mortality linked to anti-smoking campaigns. Statistical analyses estimate that at least half the mortality reduction was directly due to PSA screening.
However, this victory came at a cost. The vast majority of prostate cancers detected were low risk—Gleason 3+3 pattern, low grade, low stage. These men often underwent aggressive treatments (surgery, radiation, hormone therapy), leading to a secondary crisis: overtreatment of cancers that would never have become life-threatening.
Overtreatment: A Public Health Crisis
By the 1990s and 2000s, treating nearly every prostate cancer was the norm, regardless of risk level. Data from cancer registries consistently showed that over 50% of diagnosed cancers were low risk, yet almost all received aggressive treatments. Only 8% of men with the lowest risk were managed with active surveillance, and nearly none with intermediate risk qualified.
This overtreatment led to significant side effects—urinary, sexual, and bowel problems—without a survival benefit in low-risk cases. The consequence was mounting discomfort among primary care providers and the 2012 recommendation by the U.S. Preventive Services Task Force (USPSTF) to halt routine PSA screening, causing a decline in diagnoses and a worrying stabilization (and recent increase) in mortality.
The Birth and Growth of Active Surveillance
Reluctance to treat low-risk prostate cancer aggressively inspired pioneers at UCSF, University of Toronto, and Johns Hopkins to develop active surveillance protocols in the early 1990s. These initially academic programs tracked patients carefully, intervening only if cancers showed signs of progression. Early trials like PIVOT and ProtecT confirmed that immediate treatment offered no survival advantage over surveillance for low-risk men, underscoring the safety of this conservative approach.
But uptake was slow. In the community, fewer than 10% of eligible men received surveillance even into the early 2010s. Things changed rapidly after the 2012 USPSTF recommendation, with surveillance rates in registries rising from under 10% to 40% by 2013, and up to 60% today according to large national registries. Yet, variation in practice remains extreme—some urologists never offer surveillance, while others do almost exclusively.
Current Guidelines: Clearer Than Ever
Today, both the American Urological Association (AUA) and the National Comprehensive Cancer Network (NCCN) designate active surveillance as the standard of care for nearly all men with Grade Group 1 (Gleason 3+3) prostate cancer. There's consensus that very low risk, previously defined in the era of six-core non-targeted biopsies, is now obsolete—most cases diagnosed today would not even warrant a biopsy under current risk stratification paradigms.
The debate over terminology continues. Many experts argue that we should no longer label Grade Group 1 lesions as "cancer" due to their indolent nature, advocating for alternative terms like “premalignant” or “atypical.” The psychological burden and insurance impacts of a “cancer” diagnosis remain significant barriers to optimal care.
Personalizing Surveillance Strategies
Effective surveillance in 2025 means tailoring intensity to the individual:
Low-volume, low-risk (Grade 1, low PSA density): For older men or those with shorter life expectancy, watchful waiting is sufficient—no need for repeated biopsies or MRIs.
Fit men with low but not minimal risk: Fewer biopsies, with longer intervals, can be safely considered.
Men with higher volume Grade 1 or marginal Grade 2 disease: Standard surveillance with regular biopsies and imaging remains appropriate.
Higher-risk men: Active treatment is generally recommended, but surveillance is sometimes still offered in borderline cases, emphasizing that deferral—not avoidance—of treatment is the likely outcome.
Importantly, the VA system has emerged as a national leader, with about 80-90% of eligible men managed by surveillance or watchful waiting.
Challenges and Innovations
Despite progress, many men still are not optimally surveilled. Only 25% of men in some networks actually received the minimum recommended follow-up (three PSAs plus a biopsy in two years). Continued efforts are needed to ensure surveillance is genuinely “active.”
Looking forward, advances in MRI, AI for image and pathology interpretation, molecular biomarkers, and more sophisticated risk stratification systems (like the CAPPRA score and dichotomized Gleason grading) promise to sharpen our definition of “low risk” and further reduce unnecessary treatment.
Focal therapy—targeting just the tumor within the prostate—may also expand, helping men who are borderline surveillance candidates avoid or delay more aggressive therapies.
Conclusion
The story of active surveillance in prostate cancer is one of science, policy, and advocacy aligning to spare thousands of men needless suffering. In 2025, active surveillance is the standard of care for nearly all low-risk prostate cancers, with nuanced expansion into some favorable intermediate risk cases. The focus is now on further reducing overtreatment, improving risk assessment, and perhaps reconsidering the very words we use to describe what is often a harmless finding.
Finally, every advancement in this journey is a product of robust, federally funded research. Continued progress in saving lives—and in sparing men from harm—depends on ongoing investment, advocacy, and education. The future for men diagnosed with prostate cancer has never been brighter, so long as we safeguard the research that brought us here.
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