A major shift in how prostate cancer is managed across the US Department of Veterans Affairs health system has allowed far more veterans with favorable-risk disease to avoid immediate treatment, according to a new Research Letter published in JAMA. The analysis describes a dramatic rise in the use of active surveillance or watchful waiting, approaches designed to monitor cancer carefully rather than automatically treating it with surgery or radiation. For veterans diagnosed with low-risk prostate cancer, the use of these noninterventional strategies increased from 27% to 93%. Among patients with favorable intermediate-risk disease, use rose from 14% to 61%. The findings suggest that the VA has made substantial progress in reducing potentially unnecessary treatment for cancers that may never threaten a patient’s health.
Prostate cancer is one of the most commonly diagnosed cancers in men, but not every tumor behaves aggressively. Many prostate tumors grow so slowly that they may never cause symptoms or shorten a person’s life, particularly when detected in older adults or in patients with other serious health conditions. Historically, however, a diagnosis could lead quickly to radical prostatectomy, radiation therapy, or other interventions. These treatments can be lifesaving for aggressive disease, but they may also cause long-term complications, including urinary incontinence, erectile dysfunction, bowel problems, and other effects that can significantly alter quality of life. Active surveillance emerged as a way to separate cancers requiring immediate treatment from those that can be safely monitored.
The strategy is not the same as ignoring cancer. Active surveillance generally involves regular testing, including prostate-specific antigen measurements, repeated clinical evaluations, imaging such as magnetic resonance imaging, and, when appropriate, follow-up biopsies. The purpose is to detect biological or pathological signs that a tumor is becoming more dangerous. If evidence of progression appears, treatment can still be offered. Watchful waiting is related but usually less intensive and is often used when the goal is to manage symptoms or overall health rather than to pursue curative treatment. Both approaches reduce the risk that a patient will experience treatment-related harm when the cancer itself poses little immediate danger.
The new study focuses on care delivered throughout the national VA Healthcare System, one of the largest integrated health systems in the United States. Its findings are important because the VA serves a broad veteran population and maintains an extensive clinical infrastructure capable of tracking diagnostic and treatment patterns across many facilities. The reported increase indicates that conservative management is no longer limited to specialized academic centers or individual physicians who have adopted it early. Instead, it has become a much more common part of routine prostate cancer care within the VA, suggesting that system-wide policies, clinical education, improved risk classification, and greater confidence in surveillance may have influenced medical decision-making.
The most striking change occurred among veterans with low-risk prostate cancer. In this group, the proportion managed with active surveillance or watchful waiting rose from just over one in four patients to nearly all patients. A shift from 27% to 93% represents more than a gradual change in clinical preference; it signals a fundamental transformation in the default response to a favorable diagnosis. For many patients, the new approach may mean avoiding surgery or radiation altogether, while retaining the possibility of treatment if their disease later shows evidence of progression. The result could be fewer avoidable complications without sacrificing the opportunity for curative intervention in men whose cancers become more threatening.
The increase was also substantial for favorable intermediate-risk disease, although the final proportion was lower. Use of surveillance or watchful waiting rose from 14% to 61%, meaning that a majority of veterans in this category were managed without immediate definitive treatment. Intermediate-risk disease is more complex because it includes tumors with a greater possibility of progression than low-risk cancers. Some patients may still benefit from treatment at diagnosis, while others may have tumors whose biological behavior remains sufficiently favorable for careful monitoring. The finding that surveillance expanded in this group suggests that clinicians are increasingly incorporating individual tumor characteristics, patient age, life expectancy, preferences, and competing medical conditions into treatment decisions rather than relying on risk labels alone.
The study also highlights why quality matters alongside incidence. Increasing the number of men placed on surveillance is not enough if follow-up is inconsistent or if patients do not receive the testing needed to identify progression. High-quality active surveillance requires reliable systems for scheduling repeat assessments, communicating results, reviewing imaging and pathology, and ensuring that a patient can transition promptly to treatment when necessary. In a large healthcare network, these processes can be difficult to standardize. The researchers’ emphasis on the quality of surveillance indicates that the success of conservative management depends not merely on delaying treatment, but on maintaining an organized clinical safety net around every patient.
Despite the overall improvement, the findings point to continuing disparities in care. The summary of the study indicates that some veterans still do not receive comparable management for favorable-risk prostate cancer, although the available information does not specify which demographic, geographic, socioeconomic, or clinical groups are most affected. Differences may arise from access to urologists, availability of magnetic resonance imaging or confirmatory biopsy, variation among medical centers, health literacy, transportation barriers, or differences in how clinicians and patients understand the risks of surveillance. Addressing such gaps will require more than publishing guidelines. Health systems may need standardized protocols, decision-support tools, patient education, quality audits, and targeted resources for facilities or populations where surveillance is used less consistently or delivered with lower quality.
The results arrive during a broader reassessment of cancer treatment, in which the central question is increasingly not simply whether a tumor can be treated, but whether it needs to be treated immediately. For veterans with favorable-risk prostate cancer, the VA experience suggests that careful monitoring can become the dominant form of care when a health system aligns clinical practice with the biology of the disease. The findings do not mean that surgery and radiation are unnecessary for all prostate cancer patients, nor that surveillance is risk-free. They show instead that a diagnosis can be managed with greater precision, reserving intensive treatment for cancers most likely to benefit from it. By helping many men avoid unnecessary intervention while preserving a pathway to treatment, the VA’s shift may offer a model for improving cancer care beyond the veteran population.
Subject of Research: Prostate cancer management and the use and quality of active surveillance or watchful waiting in the US Department of Veterans Affairs Healthcare System.
Web References: https://doi.org/10.1001/jama.2026.13471
References: Cooperberg MR et al., Research Letter published in JAMA, DOI: 10.1001/jama.2026.13471.
Keywords: Prostate cancer, active surveillance, watchful waiting, Veterans Affairs Healthcare System, low-risk prostate cancer, favorable intermediate-risk prostate cancer, cancer treatment, overtreatment, health disparities.
