The intent of active surveillance is to maintain patients’ QOL by deferring or delaying definitive treatment when prostate cancer is unlikely to cause mortality or significant morbidity, while simultaneously maintaining the potential to implement definitive treatment with curative intent should this become necessary. Relevant data to inform management for patients with low-risk prostate cancer may be found in the ProtecT trial,122 which randomized 1,643 patients with clinically localized prostate cancer to surgery, radiation therapy, or active surveillance (referred to as active monitoring in the trial). In total, 77% of patients in the trial had a Gleason score of 6, 76% had clinical stage T1c (non-palpable) disease, and approximately two-thirds of patients had low-risk prostate cancer.18 The incidence of all-cause mortality for radical prostatectomy, radiation therapy, and active monitoring was 10.1, 10.3, and 10.9 per 1,000 person-years, respectively (P=0.87). Moreover, no significant differences were identified in prostate cancer-specific mortality. As such, the trial provides high-level evidence supporting the concept that selected patients with prostate cancer can delay or altogether avoid treatment. These results from ProtecT reinforced numerous cohort studies that have documented the outcomes of patients managed with active surveillance for low-risk prostate cancer and consistently demonstrated low rates of metastases (<1.5%) and prostate cancer related death (<1%) within 10 years after diagnosis.123-129 Given the demonstrated relative safety of active surveillance, the Panel believes that the benefits of aggressive treatment do not outweigh the risk of treatment-related harms for most patients with low-risk disease. Indeed, the potential adverse events associated with prostate cancer treatment, predominantly urinary morbidity, bowel complications, and sexual dysfunction, have been well documented.130-132 The Panel nevertheless acknowledges that select patients with low-risk disease may elect definitive local therapy after an informed discussion between clinician and patient. In particular, clinicians may offer immediate treatment to select patients who are fully informed as to all options and risks with low-risk prostate cancer such as those who have a high probability of disease risk reclassification on active surveillance (e.g., high-volume cancer, higher PSA density) or other risk factors for harboring higher-risk disease (e.g., family history of lethal prostate cancer, germline mutation associated with adverse pathology).133 Patients electing to proceed with active surveillance should be informed of the importance of regular cancer surveillance to avoid missing the window of curability. Strategies for monitoring disease in patients electing active surveillance are detailed further in Principles of Active Surveillance.