In Japan, the use of ASis relatively higher in academic centers and centers that participated in international AS studies (e.g., PRIAS, Prostate Cancer Research International Active Surveillance) [22]. The reluctance of Asian patients to agree to repeated biopsies and poor long-term compliance to repeated biopsies in AS protocol are other reasons that reduce patients’ incentive to agree to AS. The Japanese PRIAS cohort, who were managed mainly by academic centers, reported biopsy compliance of 83% at 1 year, 64% at 4 years, and 39% at 7 years. Biopsy compliance in nonacademic centers and in less developed countries is expected to be much lower. Poor adherence to the AS protocol may result in delayed diagnosis of disease pro­gression, loss-to-follow-up, and possibly meta­static disease and loss of window of cure. As shown in the Active monitoring arm in the PROTECT trial, a lack of a stringent AS protocol may result in a higher rate of M1 disease in the long run [23]. Patients living in rural areas in China being diagnosed in urban hospitals may not return for follow-up in the long run, and therefore, a biopsy followed by a prostatectomy within a few days may offer the best cure in one hospital attendance.

gists exploring decision-making roles in local­ized prostate cancer treatment showed that many healthcare providers still preferred a more pater­nalistic role [49]. In a multicultural, multiracial survey conducted among patients in Singapore, two-thirds of patients, if diagnosed with cancer, would want their family to participate in decision­making [50]. (Rhunke etal.) Japanese value the role of the family and doctor’s recommendations more than individual decision-making, while the reverse is true in the United States [51]. Urologists in Asia need to balance cultural traditions and generational changes to help guide the patient to the most appropriate treatment choice.