Introduction
Prostate cancer affects millions of men worldwide. But not all prostate cancers are deadly or need quick treatment. Active surveillance offers a smart option for men with low-risk prostate cancer. It helps them avoid harsh treatment side effects while keeping a close eye on their condition.
This guide explains what active surveillance is, who it works for, how it’s done, and what to expect along the way.
What is Active Surveillance?
Active surveillance means watching prostate cancer closely instead of treating it right away. It’s different from “watchful waiting” (which uses fewer tests and waits for symptoms). Active surveillance follows a clear plan of regular testing to track the cancer. If the cancer grows more aggressive, treatment can begin.
Dr. Laurence Klotz, who pioneered this approach, explains: “Active surveillance helps us treat only men with serious cancers while sparing others from needless treatment.”
What Active Surveillance Includes
- Regular PSA blood tests
- Digital rectal exams
- Periodic prostate biopsies
- MRI scans
- Genetic tests in some cases
The goal is to catch any cancer growth early enough for successful treatment. This avoids treating cancers that might never cause problems in a man’s lifetime.
Who Should Consider Active Surveillance?
Active surveillance works best for men with:
- Low-risk prostate cancer: Gleason score 6 or less, PSA under 10, early-stage tumor
- Some medium-risk cases: Select men with slightly higher scores may qualify
- Life expectancy issues: Often best for older men or those with other health problems
Dr. Matthew Cooperberg from UCSF says: “The best candidate has a small amount of low-grade cancer and understands the small risks of this approach.”
When Active Surveillance Isn’t Right
- High-grade cancer (Gleason score 8 or higher)
- Cancer found in many biopsy samples
- Fast-rising PSA levels
- Patient prefers immediate treatment
- High anxiety about living with cancer
- Strong family history of aggressive disease
How Active Surveillance Works
Most programs follow these steps:
First Steps
- Complete prostate biopsy (10-14 samples)
- MRI scan to see cancer location and size
- Baseline PSA test
- Physical exam including digital rectal exam
Ongoing Checks
- PSA tests every 3-6 months
- Physical exams every 6-12 months
- Follow-up biopsies at year 1, then every 2-5 years if stable
- Repeat MRIs every 1-2 years
When Treatment Might Start
Doctors may suggest treatment if:
- Cancer grade increases
- Tumor grows larger
- PSA levels rise quickly
- Symptoms develop
- Patient chooses to start treatment
About 30% of men on active surveillance move to active treatment within 5 years. Grade changes on follow-up biopsy are the most common reason.
Benefits of Active Surveillance
Avoiding Treatment Side Effects
Cancer treatments can cause serious side effects:
- Surgery complications:
- Erectile problems (30-70% of men)
- Urinary leakage (5-20%)
- Bowel issues (rare)
- Radiation side effects:
- Rectal bleeding (5-20%)
- Urinary urgency (10-30%)
- Erectile problems (30-50%)
Active surveillance lets men maintain their quality of life while their cancer remains slow-growing.
Mental Well-being
Research shows that men on active surveillance report quality of life similar to men without cancer after they adjust to their diagnosis.
Cost Savings
Active surveillance costs much less than immediate treatment. A 2019 study found savings of $20,000-$30,000 per patient compared to immediate surgery or radiation.
Challenges to Consider
Mental Impact
Living with untreated cancer causes anxiety for some men. About 10-15% of men choose to stop active surveillance due to worry, even when their cancer isn’t growing.
Helpful resources include:
- Support groups
- Counseling
- Education from the Prostate Cancer Foundation
Risk of Missed Changes
Despite careful checking, there’s a small chance doctors might miss cancer growth between tests. New methods help reduce this risk:
- MRI-guided biopsies improve accuracy
- Genetic testing helps find aggressive tumors
- New blood tests can help predict cancer growth
Choosing the Right Patients
Dr. Stacy Loeb from NYU says: “Picking the right patients is key to successful active surveillance. We must balance the risks of undertreating serious cancer against overtreating harmless disease.”
New Advances
Better Imaging
MRI scans have changed active surveillance by:
- Finding important cancers with 90% accuracy
- Allowing targeted biopsies of suspicious areas
- Reducing the need for repeated biopsies
- Providing non-invasive monitoring
New PET scans also show promise for tracking cancer.
Genetic Testing
Several tests can help predict cancer risk:
- Oncotype DX: Analyzes 17 genes
- Prolaris: Measures cell growth genes
- Decipher: Checks 22 markers linked to spread
These tests help find men who seem low-risk but might have more aggressive disease.
Blood and Urine Tests
New tests that detect cancer markers are being developed:
- SelectMDx: Urine test for cancer markers
- ExoDx Prostate: Checks RNA in urine
- Circulating tumor DNA: Blood test for cancer DNA
These tests may someday reduce the need for biopsies.
Patient Experience
Making Decisions Together
The choice to use active surveillance should involve talks between patient and doctor about:
- Medical facts (cancer features)
- Patient values and wishes
- Comfort with uncertainty
- Age and overall health
Decision tools and education can help patients understand their options.
A Patient’s Story
Michael S., on active surveillance for 8 years, shares: “At first, I worried about ‘doing nothing,’ but my doctor helped me see we were actually doing quite a lot—just not rushing into treatment. I’m glad I kept my quality of life without the side effects my friends had after surgery.”
Family Involvement
Partners and family often help with decisions and provide support. Research shows partners sometimes worry more than patients, showing the need to include loved ones in education.
Long-Term Results
Survival Rates
Large studies show excellent long-term outcomes:
- The ProtecT trial found no major difference in 10-year survival between watching, surgery, and radiation for low-risk patients
- A 15-year study showed 98% disease-specific survival among 1,000+ men on active surveillance
- Johns Hopkins reported 99.9% freedom from cancer spread at 10 years for very low-risk cases
Quality of Life
Studies consistently show better quality of life (sexual, urinary, and bowel function) for men on active surveillance compared to those getting immediate treatment.
Moving to Treatment
For men who eventually need treatment:
- Treatment outcomes match those who had immediate treatment
- The “window for cure” generally stays open
- Most men are glad they delayed treatment and its side effects
Guidelines
Medical Organization Advice
Major medical groups now support active surveillance:
- American Urological Association: Recommends active surveillance as the best option for very low-risk cancer
- European Association of Urology: Strongly recommends it for low-risk disease
- National Comprehensive Cancer Network: Lists it as the preferred strategy for low-risk cancer
Program Differences
While the basic approach is similar, programs vary:
- Johns Hopkins: Yearly biopsies for 5 years, then every 3-5 years
- UCSF: Biopsies at years 1, 2, and 5, then every 3-5 years if stable
- Sunnybrook: Biopsies at years 1, 4, 7, and 10 unless PSA changes
- European PRIAS: Follow-up based on PSA changes
Future Directions
Research Focus
Ongoing research looks at:
- Better tests to find aggressive cancer
- Optimizing check-up schedules to reduce invasive tests
- Understanding the genetics of slow vs. fast-growing cancer
- Testing the role of medications during active surveillance
New Ideas
Some centers are exploring:
- Selective treatment: Using focal therapies on main tumors while watching the rest
- Risk-based monitoring: Tailoring check-up frequency to individual risk
- AI assistance: Using algorithms to predict risk and plan follow-ups
Practical Matters
Insurance Coverage
Most insurance plans cover active surveillance, recognizing both medical need and cost savings. Some newer tests (advanced imaging, genetic testing) may have varying coverage.
Lifestyle Choices
Many doctors suggest lifestyle changes during active surveillance:
- Regular exercise (may help slow cancer growth)
- Plant-rich diet with less red meat
- Healthy weight
- Quitting smoking
- Stress management
While direct impact on prostate cancer is still being studied, these changes support overall health and may affect cancer behavior.
Common Questions
Q: Is active surveillance the same as “doing nothing” or “watchful waiting”?
A: No. Active surveillance follows a structured plan of regular testing to monitor cancer closely. We plan to treat if needed. Watchful waiting is less intensive and focuses on managing symptoms.
Q: What are my chances of cancer growth during active surveillance?
A: About 30% of men show changes within 5 years that lead to treatment. This varies based on your risk factors. More than 98% of well-selected men don’t develop cancer spread.
Q: How painful are repeat biopsies?
A: Most men report moderate discomfort. We use local numbing, and the procedure takes 10-15 minutes. Some centers now offer MRI-targeted biopsies that need fewer samples. Side effects may include minor bleeding and infection risk (1-4%).
Q: Can I ever stop active surveillance if my cancer stays stable?
A: Some programs reduce testing for older men after years of stability. Most guidelines suggest lifelong monitoring, but with less frequent tests based on stability and age.
Q: What new technologies might reduce the need for repeat biopsies?
A: Advanced MRI techniques, blood and urine tests, and genetic tests are being studied as ways to reduce biopsy frequency while maintaining safety.
Conclusion
Active surveillance offers a smart approach to prostate cancer management. It helps men avoid overtreatment while staying safe if they have low-risk disease. As imaging, testing, and risk assessment improve, active surveillance will likely become even more personalized and less invasive.
This approach recognizes that many prostate cancers grow slowly and won’t cause harm. It still provides a clear path to treatment for cancers that become more aggressive.
For the right patients, active surveillance maintains quality of life without compromising cancer control. It truly offers personalized care that balances the risks of both undertreating and overtreating cancer.