For men diagnosed with low-risk prostate cancer, watchful waiting rather than immediate treatment has become the clinical standard — yet adoption of this approach remains inconsistent across U.S. healthcare systems. Understanding where and why active surveillance is underutilized matters enormously, because unnecessary treatment carries real costs: incontinence, erectile dysfunction, and cardiovascular strain from hormone therapy, all for cancers that may never progress meaningfully within a patient's lifetime.
This research letter published in JAMA examined patterns of active surveillance use within the national Veterans Affairs Healthcare System — one of the largest integrated healthcare networks in the United States — among men diagnosed with favorable-risk prostate cancer. The analysis tracked both the incidence of active surveillance selection and markers of surveillance quality, meaning whether men who chose watchful waiting received appropriate follow-up biopsies and PSA monitoring at recommended intervals. The findings reveal meaningful variability across VA facilities, suggesting that institutional and provider-level factors — not just patient preference — drive whether eligible men receive guideline-concordant care.
The broader clinical context is important here. Major urology guidelines from both the American Urological Association and the National Comprehensive Cancer Network have endorsed active surveillance as the preferred management strategy for low-grade, localized prostate cancer since roughly 2016, yet real-world uptake has lagged. Prior research in community and academic settings has shown rates hovering between 40–60% for eligible patients, with racial and socioeconomic disparities compounding the gap. The VA system, with its standardized electronic health records and relatively uniform access structure, offers a uniquely powerful lens for examining system-level versus patient-level determinants. The study's limitation is its observational design — it can describe patterns but cannot establish why surveillance quality varied. Still, as a population-level audit of an underexplored cohort, this is a clinically meaningful contribution that should inform VA quality-improvement initiatives.