Active Surveillance of Prostate Cancer

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“There are a lot of prostate cancers that don’t necessarily need to be treated right away,” says UC San Diego urologist J. Kellogg Parsons. “About 15 to 20 percent of newly diagnosed men meet the strict criteria for active surveillance. Active surveillance is an important alternative that we talk to patients about.”

What is Active Surveillance?

The goal of active surveillance is to monitor cancer that is growing very slowly and will not likely do any harm for a long time, if ever. Active surveillance may be a strategy for you as long as the cancer meets certain criteria. Treatments such as surgery or radiation therapy are initiated if surveillance indicates that the cancer is growing.

Active surveillance does not refer to men with elevated PSA who avoid diagnostic tests by watching their PSA. Men with abnormal rectal exams or elevated PSA should be seen by a urologist so that additional diagnostic tests (e.g. imaging, lab tests, MRI-directed biopsy, etc.) can be performed.

Who is a Candidate for Active Surveillance?

Men with low-risk prostate cancer may be candidates for active surveillance if they meet the following:

  • Low PSA of less than 10
  • Low PSA density of less than 0.15 ng/mL/cc of prostate volume
  • Low volume of cancer on prostate biopsy. Namely, less than or equal to three biopsies involved out of 12 with no more than 50 percent of a single biopsy core
  • Gleason score less than or equal to 6
  • Stage T1C or T2A

About 15 to 20 percent of newly diagnosed men meet the strict criteria for active surveillance. When older, less healthy men are included, at least a third of newly diagnosed men may be appropriate candidates. Active surveillance is not appropriate for men with more aggressive prostate cancers who would benefit from immediate definitive treatment such as radical prostatectomy or radiation therapy.

Overtreatment of Prostate Cancer

Sometimes the treatments for prostate cancer can cause more harm than living with the disease. While prostate cancer treatments have become increasingly sophisticated with fewer potential side effects, it is nonetheless the case that no treatment is free of side effects. Overtreatment is the treatment of a disease that was never destined to cause harm. This type of treatment doesn’t enhance length or quality of life. 

If you are an 85-year-old man diagnosed with low-risk prostate cancer, or you have other health problems, undergoing surgery or radiation may offer no benefit because the cancer may not progress to a point that causes any symptoms over the length of your life.

Delay of Prostate Cancer Treatment

Delaying therapy in favor of careful surveillance, with the expectation of delivering treatment if the disease progresses, is an important option. 30 to 40 percent of men who choose active surveillance with their urologist will require prostate cancer treatment eventually. If you are a younger man diagnosed with low-risk prostate cancer, research has shown that if you start in an active surveillance program after diagnosis and then end up needing treatment, the outcomes rates after treatment are the same as for those who are treated at the time of diagnosis.

What possible benefit could there be to delaying treatment?  Advances in prostate cancer therapy may make tomorrow’s treatment even more effective than what is available today. Keep in mind: Active surveillance is for men whose cancer meets particular criteria for risk assessment. Delaying treatment is not for men with high-risk prostate cancer.

Follow up during active surveillance is rigorous so that any early evidence of disease progression is caught and treatment is initiated.

J. Kellogg Parsons, MD, MHS, discusses active surveillance or watchful waiting, and explains who is an appropriate candidate for this treatment option. (7min. 11sec.)

What does the follow up for active surveillance entail?

  • PSA testing every three months
  • Physical exam every six to 12 months
  • Biopsy every 12 months following the biopsy that diagnosed the cancer

Keeping in mind that prostate cancer is common and typically slow growing, we make sure to talk to our patients who have low-risk prostate cancer about active surveillance. Learn more about active surveillance, treatment options and risk assessment.