We thank Hotston et al for their letter. They point out that active surveillance (AS), which is predicated only on the current standard method of diagnosis under-stages and under-grades newly diagnosed prostate cancer. We agree with them.
We do not ‘counsel against the use of AS’, but noted that men should be counselled carefully and given a chance to consider all options , which is the point that BAUS made in their clarification agreed with the National Institute for Health and Clinical Excellence (NICE) in 2009. Whilst we personally think that AS is a good method of management for many low-risk men, evidence is still accumulating to show that AS provides good long-term outcomes (>8–10 years)  that compare with other methods of management .
We agree with them that TRUS-guided biopsies, as currently practiced with 10 or 12 needle tracks, have real flaws as indicated in our own paper, and we
agree with them that in due course one hopes that there is a better method of diagnosis.
We agree that the right way forward for AS is a more careful assessment of men with presumed low-risk disease. Whether this is through biomarkers, high-quality MRI or template biopsies will be the outcome of carefully done research, which will have to include measures of cost-effectiveness and complications. The cost of a template biopsy under general anaesthetic is significant, can take a significant amount of time, and probably more time for the pathologist, and carries side-effects including the increased risk of urinary retention. All of these factors need to be carefully considered as we seek to improve evaluation of men presumed suitable for AS.