Active Surveillance in Low- and Intermediate-Risk Prostate Cancer: Comparative Oncologic Safety, Patient Selection, and Predictors of Treatment Conversion in the Era of Multiparametric MRI: A Systematic Review and Meta-Analysis

Abstract

Simple Summary Prostate cancer that is diagnosed at an early stage and deemed low-risk is increasingly managed through active surveillance. Prioritizing close clinical monitoring over immediate surgical intervention or radiotherapy protects patients from substantial treatment-related toxicities without compromising long-term survival. In this systematic review and meta-analysis, we synthesized evidence from 29 prospective studies and randomized trials comprising 46,318 men. Patients managed on active surveillance exhibited long-term cancer-specific survival comparable to those undergoing immediate radical treatment, while demonstrating substantially superior preservation of urinary, sexual, and bowel function. Sequential multiparametric MRI provided high negative predictive reliability for ruling out high-grade upgrading, supporting selective biopsy deferral under strict protocolized conditions. However, the presence of invasive cribriform histology was strongly associated with disease reclassification, indicating that such patients warrant close surveillance or timely curative intervention. These synthesized findings consolidate active surveillance as a safe standard of care for low-risk disease while establishing risk-adapted boundaries for monitoring intermediate-risk prostate cancer.