The case for active surveillance as the optimal therapy for screen detected, low volume, low grade prostate cancer is presented. This is based on data from recent long term studies of conservative management, the prostate cancer prevention trial (PCPT), the Swedish trial of radical prostatectomy vs. observation, and several large Phase 2 trials of active surveillance. These studies indicate convincingly that (1) widespread screening results in a diagnosis of prostate cancer in many patients with clinical insignificant disease, (2) that these patients can be identified with reasonable accuracy, (3) that delayed intervention does not appear to put those patients who reclassify as higher risk over time at significant risk, and (4) that the psychological burden of surveillance is acceptable.