The concept of active surveillance, has increasingly emerged since 2010 as a viable option for men who decide not to undergo immediate radical treatment (e.g. surgery or radiation therapy).
Similarly to the concept of observation, a lot of prostate cancer is unlikely to harm you or decrease your life expectancy. The concept of active surveillance is not “no treatment”, but rather to treat you when your cancer warrants treatment (some think of it as deferred treatment). We now know that men with low risk prostate cancer 10-15 years after their diagnosis who go on active surveillance have remarkably low rates of their disease spreading or dying of prostate cancer. In fact, one study from Johns Hopkins in very favorable men followed on active surveillance found that <1% of men had meaningful progression of their disease 15 years later. This demonstrates that for these men there would be no difference in outcomes if they had immediate treatment or underwent active surveillance. The key to these successful numbers though is making sure you are monitored regularly, and that you undergo treatment if your disease becomes more aggressive.
Active Surveillance Questions
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During active surveillance, prostate cancer is carefully monitored for signs of progression. A PSA blood test and digital rectal exam (DRE) are usually administered once or twice a year along with a repeat biopsy of the prostate usually every 1-3 years. If there is evidence that the cancer is progressing treatment might be warranted.
It is important to note that 50-66% of men during the 10 years after their diagnosis stay on active surveillance and don’t warrant treatment. Therefore, the benefit of active surveillance in most men is the avoidance of treatment, and for the rest of the men a delay in having to experience the side effects of treatment.
When to Choose Active Surveillance
Current estimates indicate that many more men are aggressively treated for prostate cancer than is necessary to save a life from the disease. Today, the man who is ideal for active surveillance has a low risk prostate cancer (low grade (grade 1 or Gleason 6), PSA <10, and the cancer is confined to the prostate). Additional factors that are often considered favorable are a low volume of cancer (small amount of cancer found on biopsy, for example).
Active surveillance might also be a good choice for older men who are not good candidates for observation, but have a limited life expectancy. In addition, if a man is currently battling other serious disorders or diseases, such as heart disease, long-standing high blood pressure, or poorly controlled diabetes, his doctors might feel it is in his best interest to hold off on immediate therapy and avoid its potential complications.
The right age for active surveillance is a difficult question, as clearly younger men will live longer with their cancers, and thus have a higher likelihood that their cancer could progress. However, in general, younger men appear to have less biologically aggressive cancers and may be able to stay on active surveillance longer. Younger men also have more to lose when it comes to quality of life as they often have better erectile and urinary function.
Current national recommendations recommend active surveillance as the treatment of choice for most low risk men.
Research is ongoing on how to best use active surveillance for intermediate risk prostate cancer.
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Terms to know from this article:
Active surveillance is an option offered to patients with very low-risk prostate cancer (low grade, low stage, localized disease). Patients are monitored carefully over time for signs of disease progression. A PSA blood test and digital rectal exam (DRE) and prostate biopsy are performed at physician-specified intervals. Signs of disease progression will trigger immediate active treatment.
Increase in the size of a tumor or spread of cancer in the body.
The removal of cells or tissues for examination under a microscope. When only a sample of tissue is removed, the procedure is called an incisional biopsy or core biopsy. When an entire lump or suspicious area is removed, the procedure is called an excisional biopsy. When a sample of tissue or fluid is removed with a needle, the procedure is called a needle biopsy or fine-needle aspiration.
The grade of a tumor depends on how abnormal the cancer cells look under a microscope and how quickly the tumor is likely to grow and spread. Grading systems are different for each type of cancer.
Gleason Score (GS) - Gleason Grade: A system of grading prostate cancer cells based on how they look under a microscope. Gleason scores range from 2 to 10 and indicate how likely it is that a tumor will spread. A low Gleason score means the cancer cells are similar to normal prostate cells and are less likely to spread; a high Gleason score means the cancer cells are very different from normal and are more likely to spread.
prostate-specific antigen (PSA): A substance produced by the prostate that may be found in an increased amount in the blood of men who have prostate cancer, benign prostatic hyperplasia, or infection or inflammation of the prostate.