Active Surveillance in Low- and Intermediate-Risk Prostate Cancer: Comparative Oncologic Safety, Patient Selection, and Predictors of Treatment Conversion in the Era of Multiparametric MRI: A Systematic Review and Meta-Analysis

Background/Objectives: Active surveillance (AS) is the preferred management strategy for localized low-risk prostate cancer. However, clinical debate persists regarding long-term oncologic safety beyond 10 years, the diagnostic reliability and false-negative risk of serial multiparametric MRI (mpMRI) for biopsy deferral, and the prognostic magnitude of adverse pathological patterns such as invasive cribriform morphology. This study aimed to provide a comprehensive meta-analytic synthesis of long-term oncologic survival, dynamic imaging performance, multivariable progression predictors, and longitudinal patient-reported functional outcomes.

Methods

Registered with PROSPERO (CRD420261479059) and conducted per PRISMA 2020 and GRADE guidelines, electronic searches were performed across PubMed/MEDLINE, Web of Science, Scopus, and Cochrane CENTRAL through January 2026. Twenty-nine prospective cohorts, randomized trials, and diagnostic imaging studies comprising 46,318 patients were included. Time-to-event survival outcomes were synthesized using Generalized Linear Mixed Models (GLMMs) and random-effects inverse-variance models (REML). Diagnostic accuracy of serial mpMRI was modeled via bivariate random-effects meta-analysis (Reitsma approach). Multivariable-adjusted hazard ratios (aHRs) and longitudinal EPIC-26 domain scores were quantitatively pooled.