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Background: While active surveillance (AS) is an established standard of care for low-risk (LR) prostate cancer (PCa), its utility for intermediate risk (IR) PCa is less evident. Prior studies were limited by the inability to differentiate between AS and watchful waiting (WW). Using a recent update in the Surveillance, Epidemiology and End Results (SEER) Database that allows for enhanced distinction between AS and WW, we aimed to compare survival outcomes of men with LR and IR PCa treated with either AS, WW or active treatment (AT).

Methods: 166,244 men were initially identified by biopsy Gleason Grade Group (GG) alone – GG1 and GG2. 94,891 patients were further stratified by National Comprehensive Cancer Network (NCCN) risk categories – LR, favorable IR (fIR), and unfavorable IR (uIR). Predictors of cancer-specific (CSS) and overall survival (OS) were analyzed, stratified by risk classification and initial treatment – AT (first line curative surgery or radiotherapy), AS or WW, utilizing the new “WW recode (2010+)” variable.

Results: We found GG2 patients on AS had worse CSS and OS than GG2 patients who received AT and GG1 patients treated with AS or AT; these trends persist within the NCCN fIR and uIR cohorts. WW patients (GG1, GG2, LR, fIR, uIR) had the worst survival outcomes of any cohort (log rank tests p<0.05).

Conclusions: We demonstrate a significantly worse 5-year CSS and OS for men with GG2, fIR, and uIR PCa treated with AS compared to AT. Our analysis suggests that AS should not be the preferred treatment modality for IR PCa.