Prostate Cancer 911

Active Surveillance

What Is Active Surveillance?

Active surveillance is a treatment plan that involves closely monitoring a patient’s condition, but not providing any treatment unless there are changes in test results that show the condition is getting worse. It is also called active monitoring. It is the preferred option for the initial management of men with localized low-risk prostate cancer. Active surveillance is also used to avoid or delay the need for treatments which can cause side effects or other health-related problems. If there are signs that the cancer may be growing, the patient will be offered a treatment.

This approach may be suitable for early prostate cancer due to the fact this disease often grows slowly and may never cause life-threatening effects. Some prostate cancer patients may never need treatment.

What Does Active Surveillance Involve?

During active surveillance, certain exams and tests are done on a regular schedule. The tests you have, and how often you have them, will depend on your doctor. These include:

  • PSA tests Your doctor will look for some important indicators in this simple blood test. For example, the doctor will analyze how often your PSA level is rising. These changes may occur in a period of a year or even more. This factor is called the PSA velocity.

Also, the doctor will take into account the time needed for the PSA level to double (eg: from 3 to 6). This is the PSA doubling time.

The PSA density is also an important factor to be taken into account. First of all, the doctor will measure the size of your prostate, probably through an MRI scan. After that, he will divide the PSA level to the volume of your prostate.

If there is a factor that may concern the doctor, he will probably recommend a biopsy to test whether the cancer is growing.

  • Digital rectal exams (DRE) During a digital rectal exam, the doctor introduces a lubricated finger into the rectum to check the prostate for any abnormalities or lumpy areas that may indicate cancer growth.
  • MRI scans Before deciding upon active surveillance, the doctor will suggest having an MRI scan to check for cancer growth and whether or not it has already spread outside the prostate. While being on active surveillance, you may have an MRI scan if the results from the PSA test and /or DRE test may suggest that the cancer is growing. MRI scans prevent unneeded and painful needle biopsies.
  • Prostate biopsies You can have a prostate biopsy when you are first diagnosed with prostate cancer and decide upon active surveillance. The biopsy can determine if it’s early stage and slow-growing. Another biopsy may be needed if the results from other prostate tests suggest that the cancer is growing. Your doctor needs to discern when a biopsy is needed and when it’s not. However, if a biopsy is performed and the results clearly indicate that the cancer is growing, treatment will be recommended.

These tests are used to find any changes that suggest the cancer may be growing. You may have a PSA test every 3-4 months, a DRE exam after 12 months of monitoring and an MRI scan even more rarely. Starting with the second year of active monitoring, a PSA test, for example, can be done each 6 months. If any changes are found, then your doctor will recommend treatment to get rid of cancer.

There are men who decide upon treatment even though there are no changes that may suggest that the cancer is growing. Talk to your doctor about your concerns.

Are There Any Side-Effects?

Since you won’t be undergoing any specific treatment while you’re on active surveillance, there are no physical side effects. However, you may need to have prostate biopsies performed while on active surveillance, which itself can cause some short-term side effects. Now, many hospitals do MRI scans, which are not invasive, instead of prostate biopsies and avoid many side-effects caused by regular biopsies.

Who is eligible for active surveillance?

Active surveillance is suitable for men with localized prostate cancer that has a low risk of spreading (metastasizing). It’s also sometimes suitable for men with intermediate (medium) risk prostate cancer who want to avoid or delay treatment. Criteria for eligibility include:

  • PSA density (blood PSA level ÷ by prostate volume) of less than 0.15
  • Low volume of localized cancer
  • Biopsy Gleason score of 3+3=6 (Grade Group 1)

Your doctor will also take other factors into account, including the cancer’s stage, the patient’s age, health, family history, and personal preference. A patient’s race and ethnicity are also important factors.

What Are The Advantages And Disadvantages Of Active Surveillance?

Advantages of Active Surveillance

  • As you won’t be undergoing treatment while you’re on active surveillance, you’ll avoid the side effects associated with treatment.
  • Active surveillance won’t affect your everyday life as much as having treatment would.
  • If test results do show that your cancer is growing, there are treatments available that can still cure it.

Disadvantages of Active Surveillance

  • You may need to have more prostate biopsies performed which can cause side-effects, as well as being uncomfortable or painful.
  • Your cancer might grow more quickly than expected and become harder to treat – however, this is very uncommon
  • Your general health could potentially change and this change could make some treatments unsuitable. For example, if you were to have heart problems, you might not be able to have surgery for prostate removal, reducing your treatment options.
  • Not having treatment can cause high levels of anxiety, in some men, about the possibility of their cancer growing.

As helpful as active surveillance can be for those with low-risk prostate cancer, it isn’t right for everyone. You need to be both willing and committed to attend regular follow-up doctor visits to check on your cancer. When considering this option, you and your doctor should carefully consider factors such as your PSA score, tumor stage, Gleason score, your age, your overall health and any concerns you may have about the quality of your life going forward.

What is the difference between active surveillance and watchful waiting?

Watchful waiting is another way of monitoring prostate cancer, even though it is often confused with active surveillance.

Active surveillance is suitable for men who can still benefit from prostate cancer treatment while watchful waiting is for men who suffer from other diseases or are too old to undergo a prostate cancer treatment.

Men who are on active surveillance can have their cancer cured, while men who are on watchful waiting can only have treatment to keep cancer under control and manage symptoms.

Active surveillance involves many prostate tests, such as regular PSA tests and DRE exams/ MRI scans or biopsies. Watchful waiting is a much more passive approach, involving fewer tests. Follow-ups are usually determined by changes in the symptoms.

Talk to your doctor about whether one of these two approaches would be suitable for you and ask him/her to explain what each approach would involve.

Make sure to read about the other prostate cancer treatment options:


  1. Active Surveillance or Watchful Waiting, American Cancer Society. Web. 18 January 2019.
  2. Active Surveillance for Early-Stage Prostate Cancer, The ASCO Post. Web. 25 July 2019.
  3. A systematic review of Active Surveillance, The National Center for Biotechnology Information. Web. February 2018.
  4. Active Surveillance and Monitoring Rules, eCancer. Web. 4 June 2019.
Dr. David Samadi | Robotic Prostate Surgeon

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