Active surveillance is an established approach for men whose prostate cancer appears unlikely to cause harm in the near future. Instead of immediately having surgery or radiation, the cancer is carefully monitored and treatment is started if there are signs that it is becoming more aggressive.
Active surveillance is most commonly recommended for men with low-risk prostate cancer, although some men with carefully selected favorable intermediate-risk cancer may also be candidates.
Surveillance usually involves regular PSA tests, examinations, MRI scans, and sometimes repeat biopsies. The exact schedule varies according to the individual and the medical center.
Active surveillance is not the same as ignoring the cancer. Its purpose is to avoid or delay the possible urinary, sexual, and bowel side effects of treatment without compromising the opportunity for treatment if it becomes necessary.
Active surveillance is most appropriate when the cancer appears to have a low likelihood of growing or spreading quickly.
Typical candidates have cancer that is:
Confined to the prostate
Grade Group 1 (Gleason 3 + 3), or sometimes carefully selected Grade Group 2 (Gleason 3 + 4)
Associated with a relatively favorable PSA level and other risk factors
Limited in extent on biopsy and imaging
Age, overall health, family history, MRI findings, and personal preferences can also influence the decision.
The important question is not simply “Do I have prostate cancer?” but “What is the risk that this particular prostate cancer will cause me harm?”
Active surveillance means regularly checking the cancer for signs of change. The exact schedule varies, but monitoring may include:
PSA blood tests at regular intervals
Periodic physical examinations
MRI scans to look for changes in the prostate
Repeat biopsies when appropriate
If the PSA, MRI, biopsy, or other findings suggest that the cancer is becoming more aggressive, treatment with surgery, radiation, or another approach can then be considered.
The goal is to treat only when treatment is necessary, while continuing to watch the cancer closely enough that an important change is detected.
The major advantage of active surveillance is that it can allow a man to avoid or postpone treatment and its possible side effects while the cancer is unlikely to threaten his health.
Surgery and radiation can be very effective treatments, but they may affect urinary control, sexual function, and sometimes bowel function. For a cancer that may never become dangerous, those side effects can have an important impact on quality of life.
Active surveillance also preserves the option of treatment later. If monitoring shows that the cancer is changing, treatment can usually be started at that time.
For appropriately selected men, the aim is therefore not simply to delay treatment. It is to avoid treating a cancer that may never need treatment.
Active surveillance requires regular follow-up. There is a possibility that a cancer initially thought to be low risk will later show signs of being more aggressive.
Another concern is that a biopsy samples only portions of the prostate, so a more aggressive area of cancer can occasionally be missed initially. MRI, repeat biopsies, and other tests can help reduce this risk.
Some men also find it psychologically difficult to know that they have cancer without immediately treating it.
For these reasons, active surveillance works best when there is a clear monitoring plan and regular follow-up. If evidence shows that the cancer is progressing, treatment can then be considered.
An overview of who may be a candidate, how surveillance works, and when treatment may become appropriate.
PCRI discusses when men with Gleason 3+4=7 prostate cancer may be candidates for active surveillance and when focal therapy or other treatment might be considered.
PCRI discusses active surveillance for selected men with Gleason 3+4 prostate cancer and explains how additional testing and imaging can help determine whether treatment is necessary.