Being told you have cancer and then being advised to "wait and watch" can feel wrong. Yet for many men with low-risk Prostate Cancer, careful monitoring is the recommended treatment, not a lack of treatment. This approach is called active surveillance.
This article explains who it suits, how follow-up works, how safe it is and when treatment becomes necessary.
What is active surveillance?
Active surveillance means the cancer is actively monitored with scheduled tests, with treatment offered only if the cancer shows signs of becoming more significant. The aim is to avoid or delay the side effects of surgery and radiation, such as urinary leakage and erection problems, in men whose cancer is unlikely to harm them.
Many low-risk Prostate Cancers grow very slowly. In an older man, some would never have caused symptoms or shortened life. Treating every such cancer would mean many men accept side effects without benefit.
Active surveillance is not the same as doing nothing. It is a structured programme with a plan to treat if needed.
Who is suitable?
The decision rests on the whole picture, not on one number. Men most suitable for active surveillance usually have:
- Grade Group 1 (Gleason 3+3=6) cancer on a properly done biopsy
- A small amount of cancer in the biopsy (few cores, a limited length in each core)
- A PSA below about 10 ng/mL
- A cancer that cannot be felt, or only on one side, on examination (stage T1 to T2a)
- An MRI that shows no worrying large or high-grade area
Selected men with Grade Group 2 (Gleason 3+4=7) cancer, when only a small part is pattern 4, may also be offered surveillance after a detailed discussion. Cancers with a large high-grade component or Grade Group 3 or higher are usually treated.
Related: Gleason score and Grade Group explained · Prostate Cancer risk groups
What does follow-up involve?
A typical programme includes:
- PSA test every 3 to 6 months
- Digital rectal examination about once a year
- Prostate MRI at the start and then periodically, commonly every 1 to 2 years
- Repeat biopsy when needed, usually targeted by MRI, often within the first year and then at intervals decided by your doctor
An early confirmatory biopsy matters. The first biopsy can miss a higher-grade area, so repeating it, guided by MRI, checks that surveillance is really appropriate.
The exact schedule is individual. Following it faithfully is the most important part of the programme.
When is treatment advised?
Treatment is usually recommended if:
- A repeat biopsy shows a higher grade (for example, Grade Group 2 with more pattern 4, or higher)
- The volume of cancer increases substantially
- The MRI shows a clear change
- The PSA rises steadily in a worrying way (a single rise is often due to infection or other benign causes and is usually repeated first)
- You decide you no longer wish to continue
Moving to treatment does not usually mean the chance of cure has been lost. The follow-up is designed to catch change while the cancer is still treatable with intent to cure, most often with robotic radical prostatectomy or radiation.
How safe is it?
In long-term studies of carefully selected men, the risk of cancer spreading or of dying from Prostate Cancer while on surveillance has been very low. A proportion of men, in published series roughly one in three over about ten years, eventually move to treatment because of progression or personal choice. Many never need treatment.
These results depend on good selection and good follow-up. They do not apply to men with higher-grade cancers or to those who stop attending tests.
Active surveillance and watchful waiting
These terms are often confused.
| Active surveillance | Watchful waiting | |
|---|---|---|
| Aim | To cure if the cancer progresses | To control symptoms |
| Typical patient | Fit, with low-risk cancer | Older or with other serious illnesses |
| Follow-up | Regular PSA, MRI, repeat biopsy | Mainly symptoms and PSA |
| If cancer progresses | Treatment with curative intent | Symptom-relieving treatment |
Living well on surveillance
- Keep every appointment. Missed tests are the main risk of surveillance.
- Stay active, keep a healthy weight, eat a balanced diet and avoid smoking. These help general health and may help prostate health.
- Report new symptoms such as blood in the urine, bone pain or difficulty passing urine.
- It is normal to feel anxious before each PSA test. Sharing this with your doctor helps; some men find it reassuring to be given results promptly.
Is surveillance right for you?
It depends on your cancer's grade and volume, your MRI, your age and health, and what matters to you. Some men prefer treatment for peace of mind, and that is a reasonable choice. The right decision is the one made with full information.
Related: Prostate Cancer treatment options · Why Prostate Cancer treatment should be individualised
Guidelines
This article is consistent with the EAU Prostate Cancer guidelines, the NCCN Prostate Cancer guidelines and the AUA/SUO guideline on clinically localised Prostate Cancer.
Consultation
Dr. Anshuman Singh, Uro-Oncologist & Robotic Surgeon, sees patients in Lucknow at the Uro-Oncology OPD, Chandan Hospital (10 AM – 4 PM) and at Uro-Onco Connect, Gomti Nagar (6 – 9 PM), Monday to Friday, and by teleconsultation. PSA reports, MRI scans and biopsy reports can be shared in advance. Book a consultation.
Frequently asked questions
Is it safe to leave Prostate Cancer untreated?
For carefully selected men with low-risk cancer, monitoring under active surveillance has a very low risk of the cancer spreading, provided follow-up tests are done as scheduled. It is not suitable for everyone.
Will I definitely need treatment later?
Not necessarily. Many men remain on surveillance for years. A proportion, in some studies about one in three over ten years, move to treatment when the cancer changes or when they choose to.
Does a rising PSA always mean the cancer is progressing?
No. PSA can rise because of infection, inflammation, an enlarged prostate or recent ejaculation or cycling. A rise is usually repeated and correlated with an MRI before decisions are made.
Can I have active surveillance with Gleason 3+4=7?
Selected men with Grade Group 2 cancer and a small amount of pattern 4 may be offered it after careful discussion. Many with this grade are advised to have treatment.
What if I feel anxious about not treating the cancer?
This is common. Talk to your doctor. Choosing treatment instead, for peace of mind, is a legitimate decision.
Treatment in Lucknow
Dr. Anshuman Singh is a Uro-Oncologist and Robotic Surgeon in Lucknow. Read about Prostate Cancer treatment in Lucknow and Robotic Surgery for Urological Cancers, or book a consultation in person or by teleconsultation.
This article is for general education and does not replace a personal medical consultation.