@charlesprestridge For each of the points you bring up there are historical (sometimes decades-long) reasons why they’re being done. (I’ll cover them one-at-a-time.)

(1). The reason why active surveillance is being “pushed so hard and dogmatically” —> PSA testing has been around since the late 1980s. (I had my first PSA test in 2000.) In the early 2000s, so many men were opting for radical treatment for just a Gleason 6 (usually surgery) when it wasn’t medically necessary, that in 2012 the United States Preventive Services Task Force (USPSTF) recommended against routine prostate cancer screening thinking that stopping screening would stop overtreatment (assigning PSA screening a “D” recommendation: https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening-2012).

Prostate cancer has one of the lowest mortality rates of all cancers (< 12%; compare that to pancreatic cancer which is nearly 80%). The side/after-effects on quality-of-life from radical treatment are often worse than prostate cancer itself.

Many doctors (and insurance companies) followed that USPSTF recommendation, some did not.

That 2012 USPSTF administrative decision received much political pushback (when considering the “B” screening recommendation for breast cancer) , and in 2018 the USPSTF updated their prostate cancer screening recommendation to a “C” (https://www.uspreventiveservicestaskforce.org/uspstf/recommendation/prostate-cancer-screening) that was accompanied by the “balance” that you see now —> that low-grade, localized disease (Gleason 6 and some Gleason 7s) can almost always be followed with active surveillance. You will rarely see active surveillance recommended for a 7(4+3), and never for a Gleason 8-10 (or for certain diagnoses with certain other risk factors).

(I was on active surveillance for over 8 years (2012-2021) and didn’t have treatment until my Gleason 6 progressed to a Gleason 7).
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