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Atypical ductal hyperplasia (ADH) remains one of the few benign breast lesions for which surgical excision is routinely recommended because of the risk of underlying carcinoma, most commonly ductal carcinoma in situ (DCIS). However, increasing interest in active surveillance has emerged alongside broader trends toward surgical de-escalation and ongoing prospective trials evaluating observation for low-risk DCIS. In this commentary, we review the challenges of identifying patients with ADH at sufficiently low risk of upgrade and summarize emerging outcome data supporting active monitoring. We discuss the target trial emulation study by Rangel and colleagues, evaluating active monitoring versus surgical excision for selected patients with ADH, as well as novel tools that may further support this approach. Together, these developments suggest a growing role for individualized management strategies in ADH. See related article by Rangel et al., p. 577.