Currently available data from long-running single- and multi-center active surveillance (AS) studies show that AS has excellent cancer-specific survival rates. For AS to be effective the ‘right’ patients should be selected for which up until 5-to-10 years ago systematic prostate biopsies were used. Because the systematic prostate strategy relies on sampling efficiency for the detection of prostate cancer (PCa), it is subject to sampling error. Due to this sampling error, many of the Gleason 3+3 PCas that were included on AS in the early days and were classified as low-risk, may in fact have had a higher Gleason score. Subsequently, AS-criteria were more strict to overcome or limit the number of men missing the potential window of curability in case their tumor would be reclassified. Five to ten years ago the prostate biopsy landscape changed drastically by the addition of magnetic resonance imaging (MRI) into the diagnostic PCa-care pathway, which has by now trickled down into the EAU guidelines. At the moment, the EAU guidelines recommend performing a (multi-parametric) MRI before prostate biopsy and combine systematic and targeted prostate biopsy when the MRI is positive (i.e. PIRADS ≥3).

So because of the introduction of the MRI into the diagnostic PCa-care pathway, literature is showing that more Gleason 3+4 PCas are being diagnosed. But can it not be that the inclusion of MRI into the diagnostic PCa-care pathway causes risk inflation, resulting in men earlier eligible for AS, now being labelled ineligible for AS? Would it not be possible to include these current Gleason 3+4 PCas on AS? The authors hypothesize that the improved accuracy that comes with the introduction of MRI into the diagnostic PCa-care pathway permits to widen both the AS-inclusion and follow-up criteria. Maintaining our inclusion criteria for AS from the systematic biopsy era will unnecessarily and undesirably expose patients to the increased risk of overtreatment. The evidence behind the addition of MRI-targeted biopsies to systematic biopsies calls upon the re-evaluation of the AS inclusion criteria and research from one-size-fits-all protocols used so far, into the direction of more dynamic and individual risk-based AS-approaches.

当前来自长期单中心和多中心主动监测 (AS) 研究的可用数据表明，AS 具有出色的癌症特异性存活率。为使 AS 有效，应选择“正确的”患者，直到 5 至 10 年前才使用系统性前列腺活检。由于系统性前列腺策略依赖于检测前列腺癌 (PCa) 的采样效率，因此存在采样误差。由于这种抽样误差，许多早期包含在 AS 中并被归类为低风险的 Gleason 3+3 PCas，实际上可能具有更高的 Gleason 分数。随后，AS 标准更加严格，以克服或限制错过潜在治愈窗口的男性数量，以防他们的肿瘤被重新分类。五到十年前，通过将磁共振成像 (MRI) 添加到诊断性 PCa 护理途径中，前列腺活检的前景发生了巨大变化，现在已经被纳入 EAU 指南。目前，EAU 指南建议在前列腺活检前进行（多参数）MRI，并在 MRI 阳性（即 PIRADS ≥ 3）时结合系统和靶向前列腺活检。

因此，由于将 MRI 引入诊断 PCa 护理途径，文献显示更多的 Gleason 3+4 PCas 被诊断出来。但是，将 MRI 纳入诊断 PCa 护理途径会不会导致风险膨胀，导致男性早期符合 AS 条件，现在被标记为不符合 AS 条件？将这些当前的 Gleason 3+4 PCas 包含在 AS 上是不可能的吗？作者假设，将 MRI 引入诊断 PCa 护理途径所带来的准确性提高允许扩大 AS 纳入和随访标准。在系统活检时代维持我们的 AS 纳入标准将不必要和不利地使患者暴露于增加的过度治疗风险中。