Active Surveillance Rates Rise for Prostate Cancer in Veterans Health System

A research letter published in JAMA has revealed a shift toward active surveillance for favorable-risk prostate cancer within the national Veterans Affairs Healthcare System (VAHCS).

Analyzing data from 73,042 patients diagnosed between 2005 and 2024, researchers found that the adoption of active surveillance or watchful waiting has surged, representing the highest rates reported in any U.S. healthcare context to date. For oncology nurses, who play a vital role in patient education, anxiety management, and care coordination, these findings provide an essential benchmark for guideline-based, conservative cancer management.

Active surveillance is the preferred clinical strategy for low-risk and many favorable intermediate-risk prostate cancers, allowing patients to avoid or delay the significant toxicities of active treatments like surgery or radiation—such as urinary incontinence and erectile dysfunction. Despite clinical guidelines, previous national studies have highlighted suboptimal and variable rates of active surveillance in US community-based practices.

To evaluate surveillance uptake within the nation’s largest integrated healthcare network, a research team co-led by Grace Lee, MD of San Francisco VA Medical Center/UCSF analyzed electronic health records of veterans diagnosed with low-risk and favorable intermediate-risk disease. The study's results demonstrate an upward trajectory in active surveillance. Among veterans diagnosed with low-risk disease, initial surveillance use increased from 27% in 2005 to 93% by 2024. For patients diagnosed with favorable intermediate-risk disease, surveillance rates rose from 14% to 61% over the same period.

The investigators also performed detailed subset analyses to understand what factors drove surveillance in intermediate-risk categories. For patients with a PSA level between 10 and 20 ng/mL but GG1 disease, surveillance rates grew from 27% to 88% over the study period. For those with GG2 disease in less than 50% of biopsy cores and a PSA below 10 ng/mL, rates rose from 11% to 55%. Across individual VA facilities, overall rates of surveillance for favorable-risk disease ranged between 23% and 93%. However, for GG1 disease diagnosed between 2015 and 2024, surveillance rates ranged from 60% to 100% across nearly all facilities.

Multivariable logistic regression analysis identified several key factors independently associated with the clinical decision to pursue active surveillance. Increasing patient age (adjusted odds ratio [OR], 1.43 per decade of life; 95% confidence interval [CI], 1.39–1.47; P < 0.001) and a more recent year of diagnosis (OR, 1.21 per year; 95% CI, 1.21–1.22; P < 0.001) were strong predictors of active surveillance use. Conversely, several clinical and sociodemographic factors predicted a lower likelihood of receiving conservative management. These included having GG2 versus GG1 disease (OR, 0.13; 95% CI, 0.12–0.13; P < 0.001), a higher percentage of positive-result biopsy cores (OR, 0.88 per decile; 95% CI, 0.87–0.89; P < 0.001), and living in areas with higher socioeconomic deprivation, as measured by the Area Deprivation Index (ADI) score (OR, 0.97 per quartile; 95% CI, 0.95–0.99).

After adjusting for disease severity, racial and ethnic disparities persisted. Black or African American veterans (OR, 0.95 versus White veterans; 95% CI, 0.90–0.99; P < 0.001) and Hispanic or Latino veterans (OR, 0.85 versus non-Hispanic veterans; 95% CI, 0.76–0.95; P = 0.003) had significantly lower odds of being managed with initial active surveillance or watchful waiting.

Researchers suggested that the high overall surveillance rates in the VAHCS reflect the system's strong institutional emphasis on guideline-based care, minimal patient "opinion shopping," and a salary-based compensation structure that reduces financial incentives for active treatments. However, the authors noted that the lower utilization of active surveillance among minoritized and socioeconomically disadvantaged populations requires targeted, science-driven implementation interventions to ensure equitable care.

Oncology nurses are uniquely positioned to translate these findings into clinical practice. First, nurses must spearhead comprehensive patient education. When a patient is diagnosed with favorable-risk prostate cancer, they often experience intense anxiety, equating a cancer diagnosis with an immediate need for surgery or radiation. Oncology nurses can demystify active surveillance, reassuring patients that they are being closely monitored with regular PSA tests, physical exams, and repeat biopsies, rather than being left untreated.

Because this study highlights that Black, Hispanic, and socioeconomically disadvantaged patients are less likely to receive active surveillance, oncology nurses must act as clinical advocates. Nurses should assess patients for socioeconomic barriers, such as transportation or health literacy, and coordinate targeted navigation services. Ensuring that minoritized patients receive equitable counseling about the safety and benefits of active surveillance is a critical step in reducing unnecessary, treatment-related morbidity and improving long-term quality of life.

Reference

1. Lee G, Bihn JR, Culnan JM, et al; PROFOUND-VET Investigators. Active surveillance use for favorable-risk prostate cancer in a Veterans Affairs population. JAMA. Published online August 13, 2026. doi:10.1001/jama.2026.13471