Patients managed with active surveillance need to be counseled regarding the importance of continued follow-up as part of this management strategy. Indeed, active surveillance is distinct as a management strategy from watchful waiting, or passive surveillance, by the incorporation of follow-up cancer testing, including prostate biopsy. While the intensity of monitoring has varied among the various reported large active surveillance cohorts to date, 125, 126, 129, 163, 164 critical components include following PSA values, which the Panel advises be in general obtained no more frequently than every six months and updating a symptom assessment and physical examination with DRE every one to two years. Notably, the monitoring regimen for patients managed with active surveillance may be individualized. For example, among patients at low risk of progression or with a more limited life expectancy, a less intense follow-up schedule may be implemented.165 With regard to the use of genomic testing, as previously noted, while biopsy-based genomic testing may impact the decision of surveillance versus treatment, robust data are currently lacking for meaningful long-term outcomes among contemporary patients managed with active surveillance. In addition, serial genomic testing among patients on active surveillance should be discouraged. An increase in PSA in a patient being managed with active surveillance should initially prompt re-testing of PSA as transient PSA elevations are common and PSA kinetics have variably been associated with pathology among patients on surveillance.166, 167 Serial PSA increases, new DRE abnormalities, or other concerns for clinical progression should prompt re-evaluation with MRI and possible prostate biopsy; less frequently, direct conversion to treatment may be considered. Detection of significantly higher-volume or higher-grade disease on surveillance biopsy should then prompt discussion of definitive therapy. The decision to continue surveillance versus proceed with treatment should incorporate the principles of SDM and include the factors of age, comorbidity status, estimated life expectancy, cancer characteristics, and patient preference, balancing the relative risks of impacting quality-of-life with treatment and disease progression.