The Role of Active Surveillance in Patients with Low-Risk Prostate Adenocarcinoma Harboring a Germline Brca2 Mutation: A Critical Discussion of Recent Evidence

Abstract

Active surveillance (AS) has become the standard management strategy for low-risk localized prostate cancer in the general population because of its excellent long-term oncologic outcomes and its ability to reduce overtreatment [1,2]. However, its role in patients carrying a germline BRCA2 mutation remains uncertain. Indeed, BRCA2 is associated with an increased risk of prostate cancer, earlier onset, and more aggressive disease, with a higher risk of metastasis and poorer cancer-specific survival [1-3]. In this context, applying conventional AS criteria to this population raises a major question: does an apparently low-risk cancer in a BRCA2 carrier truly represent indolent disease, or a disease that may be underestimated at diagnosis? The 2024–2026 French CCAFU recommendations and the 2026 EAU guidelines acknowledge the unfavorable prognostic impact of BRCA2 while also emphasizing that no high-level evidence currently supports systematically excluding these patients from AS [1,2]. Available data mainly suggest an increased risk of reclassification in familial or hereditary settings, without definitive BRCA2-specific evidence [1,4]. As of 2026, AS may therefore be considered in highly selected patients, but only after rigorous initial characterization with multiparametric MRI and appropriate biopsy assessment, clear patient counseling, and intensified follow-up [1,2].