Focus should now shift to defining risk.

In this study, the authors suggest that men with favorable-risk prostate cancer should be informed of the low likelihood of harm from their diagnosis and should be encouraged to consider active surveillance rather than curative intervention. There is no doubt that, for some men diagnosed today with very-low-risk or low-risk prostate cancer, this statement is valid; however, to whom specifically, on an individual basis, this statement should apply remains unanswered.

The authors have also provided helpful information about patient-and cancer-related parameters associated with upgrading to Gleason score 7 or greater at surveillance biopsy.

These parameters included increasing age, prostate-specific antigen density, and the number of positive cores. However, information about patient factors, including comorbidity, ethnicity, and family history, should also be considered in decisions about when to use active surveillance and in which patients active surveillance will not lead to missing occult high-grade prostate cancer that can that can progress to metastasis during their remaining life expectancy.

Attention should shift away from establishing that long-term rates of metastasis and death as a result of prostate cancer are low for a population of men diagnosed with favorable-risk prostate cancer who are observed on an active surveillance protocol or who are randomly assigned to active surveillance versus intervention. Rather, the focus should be on defining a validated risk-assessment scheme that is based on a panel of cancer and patient factors capable of determining whether an individual man of a given age, health, and ethnicity, and with specific tumor characteristics, family history, and perhaps multiparametric MRI imaging characteristics, is best served by being observed on an active surveillance protocol.

Dr. Anthony V. D'Amico is from Brigham and Women's Hospital and Dana Farber Cancer Institute, Boston, and has no disclosures. These remarks were taken from the editorial accompanying Dr. Tosoian's report (Journ Clin One. 2015 Aug 31. doi: 10.1200/JCO.2015.63.6118).