Active Surveillance Follow-Up for Prostate Cancer: From Guidelines to Real-World Clinical Practice - Beyond the Abstract
On paper, AS protocols sound simple enough: regular PSA testing paired with periodic biopsies, as laid out by major guidelines like the EAU, AUA, and NCCN. But in practice, it’s a different world. Our data, drawn from a diverse North American cohort of 546 men followed over nearly three decades, revealed that only 11% of patients adhered to these idealized guidelines.
Why the disconnect? It turns out that biopsies—not PSA tests—are the sticking point. While the majority of patients managed to keep up with annual PSA monitoring, most balked at undergoing biopsies as frequently as the guidelines suggest. We supposed that for many, the discomfort, risks, and psychological burden of repeated biopsies likely outweighed the perceived benefits, especially when their PSA levels remained stable.
Interestingly, our findings suggest that for most men, this less-than-perfect adherence didn’t come with dire consequences. For patients who didn’t follow biopsy guidelines and had stable PSA levels over a median follow-up of 9.3 years, their prostate cancer-specific mortality (PCSM) was reassuringly low: 1.6%—on par with outcomes from landmark AS trials.
That said, the picture isn’t entirely rosy. Black men were significantly less likely to adhere to monitoring protocols compared to White men, highlighting persistent racial disparities in healthcare. On the flip side, patients with higher clinical tumor stages (cT2) or more comorbidities were more likely to follow the guidelines. These findings hint at a nuanced decision-making process: patients with higher risks may naturally attract closer monitoring.
One surprising twist in our study was that patients who adhered to the guidelines had a higher PCSM (8.4%) than those who didn’t (1.6%). While counterintuitive at first glance, this likely reflects a selection bias: patients who progressed during surveillance were more rigorously monitored, leading to their inclusion in the "adherent" group.
Our findings highlight a fundamental truth about AS: while guidelines provide an important framework, they don’t always align with the realities of clinical practice—or with what patients are willing to tolerate. This is where we, as a community, need to bridge the gap between trial-based protocols and real-world practice. Perhaps the future lies in more personalized monitoring strategies—ones that respect both the science and the individual patient experience.
AS was designed to strike a balance between vigilance and quality of life, and our study shows that clinicians and patients are already recalibrating that balance in the real world.
After all, the ultimate goal isn’t perfect adherence to a checklist—it’s ensuring that every patient on AS gets the right care at the right time, with the least burden possible.
Written by: Giuseppe Chiarelli, MD, Urology Resident, Humanitas University, Department of Urology, Humanitas Research Hospital, Rozzano (MI), Italy
Read the Abstract