The optimal management of men with intermediate risk prostate cancer remains unclear and continues to be debated. The authors interrogate the US National Cancer Database for 176,122 men diagnosed with intermediate risk prostate cancer between 2010 and 2016. Of these 57.3% underwent radical prostatectomy, 36.4% received radiotherapy and 3.2% were assigned to active surveillance (AS). The use of AS increased from 1.6% in 2010 to 4.6% in 2016, including those with higher risk factors. Whilst this option was used as expected in men with variables such as age and grade group 2 vs. 3, it was also found to depend on whether the diagnosis was at an academic centre, education level or insurance status but not race or comorbidities. The discussion is interesting as it highlights the potential for refined risk stratification by new technology such as genomic profiling, mpMRI and Gleason grade subtyping which may help identify occult unfavourable subgroups of intermediate risk disease.