The study followed more than 73,000 veterans receiving care through the U.S. Department of Veterans Affairs, one of the largest integrated health systems in the country. Researchers from UCSF, the San Francisco VA, VA Boston Healthcare System, Harvard Medical School, and Boston University School of Medicine analyzed treatment patterns over nearly two decades. Their work was conducted through PROFOUND-VET, a Veterans Affairs research initiative designed to develop and evaluate cancer-care guidelines. Rather than asking whether one individual treatment was superior in a randomized clinical trial, the investigators examined how real-world clinical practice changed across the VA system. The results reveal a striking transformation: a diagnosis that once commonly triggered immediate intervention is increasingly being managed through careful observation, repeated testing, and treatment only when biological evidence suggests that the cancer is becoming more dangerous.

Active surveillance is not the same as ignoring cancer. It is a structured monitoring program intended to separate tumors that remain biologically indolent from those that show signs of progression. Patients commonly undergo prostate-specific antigen, or PSA, blood testing every three to six months. PSA is a protein produced by prostate tissue, and changes in its concentration can provide clues about tumor activity, although the marker is not perfectly specific for cancer. Physicians may also perform digital rectal examinations, magnetic resonance imaging, and repeat prostate biopsies at longer intervals. MRI can reveal changes in the size, shape, or cellular characteristics of a suspicious lesion, while biopsy allows pathologists to reassess the tumor’s microscopic grade. If tests show that the cancer has grown, become more aggressive, or acquired other warning signs, the patient can move to definitive treatment with surgery or radiation.

The biological logic behind surveillance is rooted in the diversity of prostate tumors. Some prostate cancers grow slowly for many years, remain confined to the gland, and never cause symptoms or shorten a person’s life. Others are aggressive from the outset and can invade nearby tissues or spread to distant organs. Conventional screening can detect both types, but a positive diagnosis does not automatically reveal which biological path a tumor will follow. Treating every detected tumor as an immediate threat can therefore expose patients to the harms of therapy without providing a meaningful survival benefit. Prostate surgery may damage nerves and muscles involved in erections and urinary control, while radiation can contribute to urinary, bowel, and sexual problems. Active surveillance seeks to preserve those functions while retaining the option of curative treatment if the cancer’s behavior changes.

The rising use of surveillance reflects evidence accumulated over several decades, including research associated with UCSF that helped establish the approach as a national standard for low-risk disease. Long-term studies have found that carefully selected patients managed with surveillance can experience survival outcomes similar to those of patients treated immediately, particularly when the cancer has a very low likelihood of spreading. The comparison is not simply between treatment and no treatment. It is between immediate treatment for everyone and a risk-adapted strategy in which low-risk patients are monitored and higher-risk biological features prompt intervention. This distinction is crucial because the goal is not to avoid treatment at all costs; it is to ensure that treatment is directed toward tumors capable of causing harm.

The new VA data also illuminate how health-system design can influence cancer care. Grace Lee, a UCSF urology resident and physician at the San Francisco VA, said the surveillance approach may be more common in the VA than in outside clinical practices because the system can track quality measures, provide feedback to physicians, and maintain long-term continuity of care. Those features are particularly important for active surveillance, which depends on reliable follow-up rather than a single decision made at diagnosis. A patient must receive scheduled PSA tests, imaging, and biopsies, and clinicians must recognize when results warrant a change in strategy. In a fragmented healthcare environment, missed appointments, incomplete records, or changes in insurance and providers can make that process more difficult. An integrated system can create reminders, standardize protocols, and monitor whether patients remain safely within the surveillance pathway.

The study’s findings also carry a message about the consequences of prostate cancer screening. Screening can save lives by identifying aggressive cancers before they spread, when surgery or radiation may be more effective. Yet the same process can uncover tumors that would never have become clinically important. This phenomenon, known as overdiagnosis, occurs when a screening program detects a disease that would not have caused symptoms or death during the patient’s lifetime. Overtreatment follows when that diagnosis is treated as an unavoidable medical emergency. Matthew Cooperberg, senior author of the study and the Helen Diller Family Chair in the UCSF Department of Urology, said screening detects many slow-growing prostate tumors that should rarely require immediate treatment. He noted that some experts increasingly question whether the least dangerous lesions should even be labeled “cancer,” because the word can produce fear and push patients toward unnecessary procedures.

That concern does not mean surveillance is appropriate for every man with prostate cancer. Risk classification incorporates the tumor’s grade, the amount of cancer found in biopsy samples, PSA levels, clinical examination, imaging findings, and other factors. Low-risk disease generally has features associated with limited growth and a low probability of metastasis. Favorable intermediate-risk disease occupies a more complicated middle ground: some tumors in this group can be monitored safely, while others may benefit from treatment depending on the patient’s age, health, tumor volume, genetic features, and preferences. Surveillance also requires psychological readiness. Repeated tests can create anxiety, and a rising PSA does not always mean that cancer has become more aggressive. Inflammation, prostate enlargement, infection, and testing variability can all affect the marker. For that reason, treatment decisions usually depend on a pattern of evidence rather than a single abnormal result.

The researchers’ conclusions are based on observational data from veterans receiving care in the VA system, so the results do not prove that the health system alone caused the increase or that identical rates would occur in every population. Veterans may differ from privately insured patients in age, medical history, access to specialists, and the way their cancers are detected and classified. The study nevertheless provides a powerful snapshot of changing medical practice at national scale. It shows that active surveillance has moved from a pioneering concept to a mainstream response to low-risk prostate cancer, with adoption accelerating as clinical evidence, monitoring technology, and physician experience have matured. The trend may also reflect better conversations between patients and clinicians about the tradeoff between a possible reduction in cancer risk and the immediate harms of treatment.

For men newly diagnosed with low-risk prostate cancer, the central question is increasingly not “How quickly can the tumor be removed?” but “How likely is this tumor to cause harm, and how confidently can we monitor it?” The VA experience suggests that, when surveillance is organized and follow-up is dependable, most men in this category can avoid or postpone invasive treatment without abandoning cancer care. The approach transforms diagnosis into an ongoing assessment of tumor biology. As screening continues to identify more early-stage disease, the ability to distinguish dangerous cancers from indolent ones will become even more important. The dramatic rise from 27% to 93% among veterans indicates that prostate cancer medicine is entering an era in which restraint, precision, and continuous measurement may protect patients as much as immediate intervention.

Subject of Research: Active surveillance for low-risk and favorable intermediate-risk prostate cancer among U.S. veterans.

News Publication Date: August 13.

Web References: https://jamanetwork.com/journals/jama/fullarticle/10.1001/jama.2026.13471

References: JAMA study by researchers from the University of California, San Francisco; San Francisco VA Health Care System; VA Boston Healthcare System; Harvard Medical School; and Boston University School of Medicine. UCSF researchers Matthew Cooperberg and Grace Lee were quoted in the source material.

Keywords: Prostate cancer, active surveillance, cancer screening, PSA testing, prostate tumors, Veterans Affairs, urology, radiation therapy, prostate surgery, cancer overdiagnosis.

Focal therapy is designed to treat only the portion of the prostate containing clinically significant cancer rather than removing or irradiating the entire gland. Depending on the technology used, clinicians may destroy targeted tissue with heat, freezing, ultrasound energy or other forms of image-guided ablation. The concept is biologically and clinically attractive: by limiting treatment to the tumor-bearing region, physicians hope to preserve more of the surrounding prostate and reduce complications associated with whole-gland surgery or radiation. Those complications can include urinary incontinence, erectile dysfunction and other changes that may substantially affect quality of life. Yet the precision of the procedure depends on accurately identifying the important cancer within the prostate, determining whether disease is truly localized, and ensuring that untreated tissue does not contain clinically meaningful tumor.

The study was led by Quoc-Dien Trinh, M.D., M.B.A., professor and chair of the Department of Urology at the University of Pittsburgh School of Medicine. Researchers used information from the National Cancer Database to examine treatment patterns among 1,179,384 men aged 50 and older who were diagnosed with nonmetastatic prostate cancer between 2010 and 2023. Of those patients, 15,672 received focal therapy. The database provides a broad view of cancer care across the United States, allowing investigators to evaluate how treatment is being used beyond the highly selected populations typically enrolled in clinical trials. When the researchers compared the treated men with contemporary risk-based recommendations, they found that about half fell outside the groups for whom focal therapy is generally supported.

The central issue is the biological diversity of prostate cancer. Risk classification is based on factors such as prostate-specific antigen levels, tumor grade, the extent of cancer in biopsy samples and clinical imaging findings. Men with low-risk disease often have tumors that grow slowly and may never threaten their health. For many of these patients, active surveillance—regular monitoring with blood tests, imaging, repeat biopsies and clinical assessment—can avoid or delay treatment without compromising the opportunity for cure. Focal therapy in this setting may expose a patient to procedural risks and long-term side effects without providing a clear medical advantage over observation. Treating a tumor that is unlikely to progress can turn a condition suitable for monitoring into a source of avoidable harm.

The opposite concern applies to men with high- or very high-risk prostate cancer. These tumors are more likely to extend beyond the original focus, invade surrounding tissue or eventually spread to other parts of the body. Destroying a visible or biopsy-confirmed lesion may not eliminate microscopic cancer elsewhere in the prostate or beyond it. For such patients, surgery, radiation combined with hormone therapy, or other multimodal treatments may offer stronger evidence for durable cancer control. Focal therapy can be highly targeted, but that strength can become a limitation when the disease is biologically aggressive or more extensive than imaging reveals. A treatment that controls one tumor focus may not adequately address the full burden of a high-risk cancer.

For appropriately selected men with intermediate-risk disease, however, the balance can be different. These patients may have cancer significant enough to warrant intervention but localized enough that treatment confined to the dominant tumor could be reasonable. The strategy seeks to preserve healthy tissue while controlling the lesion most likely to determine the cancer’s behavior. Modern imaging, particularly multiparametric magnetic resonance imaging, can help identify suspicious areas and guide targeted biopsies, while advanced navigation systems can assist in planning ablation. Even so, imaging and sampling are imperfect. Prostate cancer may be multifocal, with clinically important disease distributed in separate regions that are difficult to detect or treat through a single targeted procedure.

The researchers stress that their analysis describes treatment patterns rather than proving that every individual procedure was inappropriate. The National Cancer Database does not contain all of the information needed to judge the clinical reasoning behind a treatment decision. It does not fully capture participation in clinical trials or prospective registries, and it lacks detailed long-term outcomes such as cancer recurrence, metastasis, retreatment, side effects, quality of life and treatment cost. A patient outside a guideline-supported category may have received focal therapy as part of carefully monitored research, or because other medical considerations made conventional treatment less desirable. Conversely, a patient who appears to fit an accepted category may still have disease features that make focal therapy unsuitable.

That limitation also highlights a broader challenge in modern medicine: the gap between technological promise and definitive evidence. New procedures can spread quickly when they offer an appealing combination of precision, reduced invasiveness and fewer visible side effects. But a lower short-term burden does not automatically mean equivalent long-term cancer control. Prostate cancer can take many years to recur or progress, making extended follow-up essential. A procedure that preserves sexual or urinary function in the first months after treatment must also be evaluated against the possibility of residual cancer, repeated treatment or delayed recognition of progression. The most meaningful comparisons will require prospective studies that track both oncologic outcomes and the patient’s lived experience over time.

The findings may therefore serve as a warning against treating focal therapy as a universal middle ground between active surveillance and whole-gland treatment. The appropriate choice depends on tumor biology, disease volume, anatomical location, imaging quality, biopsy findings, the expertise of the treatment team and the patient’s priorities. It also requires a clear discussion of uncertainty. Men considering focal therapy should understand that the approach may involve continued surveillance, additional biopsies or retreatment, and that evidence for long-term cancer outcomes remains less mature than it is for established treatments in many risk groups. Shared decision-making is particularly important when the potential benefit is preserving quality of life but the consequences of undertreating a dangerous cancer could be serious.

As focal therapy continues to expand, better patient selection could determine whether the technology fulfills its promise or becomes another example of innovation outpacing evidence. The Pittsburgh team says future research should identify the biological and imaging features that predict successful treatment, clarify which patients require additional therapy, and measure outcomes over long periods. The researchers also caution that procedures performed outside Commission on Cancer-accredited centers may not be represented in the database, meaning the national number of treated patients could be higher than reported. Their overarching message is not that focal therapy has no place in prostate cancer care, but that precision treatment must be matched with precision selection. For each patient, the goal is to choose an intervention that reflects the aggressiveness and distribution of the cancer while protecting quality of life wherever safely possible.

Subject of Research: Focal therapy use and guideline concordance in men with nonmetastatic prostate cancer.

Web References: https://www.urology.pitt.edu/people/quoc-dien-trinh-md-mba ; https://hillman.upmc.com/cancer-care/prostate ; https://www.cdc.gov/prostate-cancer/statistics/index.html

References: JAMA. DOI: 10.1001/jama.2026.12411

Image Credits: UPMC

Keywords: Prostate cancer, focal therapy, active surveillance, cancer treatment, urology, oncology, prostate cancer risk, precision medicine, JAMA, University of Pittsburgh