This is probably a tempest in a teapot. NCCN, one of the top organizations that establishes the standard-of-care in the US, has once again changed its low-risk guidelines. It caused a bit of a storm earlier this year when they removed the word "preferred" after "active surveillance" for low-risk patients. Now they have added back the words "preferred for most patients" after active surveillance in the low risk category.
They add a footnote that reads:
“The panel recognizes that there is heterogeneity across the low-risk group and that some factors may be associated with an increased probability of near-term grade reclassification, including high PSA density, a high number of positive cores (e.g.,>3), high genomic risk (from tissue-based molecular analysis), and/or a known BRCA2 germline mutation. In some of these cases, upfront treatment with radical prostatectomy or prostate radiation therapy may be preferred based on shared decision-making with the patient.”
I agree with their qualifications, but would add African-American ethnicity and PNI. They don't define what they mean by "high" PSA density. The average is 0.15 ng/ml/g. I would also use "mpMRI-estimated tumor volume > 0.5 ml" instead of "number of cores."
I believe that NCCN should have separate localized-risk categories for prostatectomy, radiation, and active surveillance because there are different variables that affect recurrence risk for each. But I am realistic enough to know that this is an uphill battle.
Trying to decide Active Surveillance vs other options
newly diagnosed and confused already
Short-term vs Long-Term ADT for High Risk Men 
