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What is active surveillance for prostate cancer?

Active surveillance for prostate cancer, like imaging and biopsies, is a way to avoid aggressive treatments.

Dr. Marc B. Garnick, MD
Hematologist & Oncologist

Men who monitor their cancer closely and plan to have treatment when its activity increases are said to be pursuing "active surveillance."

Several research groups and medical centers have developed specific criteria to better differentiate men diagnosed with early-stage prostate cancer who can pursue active surveillance (those who monitor their cancer closely and plan to have treatment when its activity increases) from those who need more immediate treatment. One of the early treatment algorithms was established, based on clinical research, by investigators at the University of Toronto. Those considered eligible for active surveillance under that algorithm have:

  • a prostate-specific antigen (PSA) of 10 nanograms per milliliter (ng/mL) or less
  • a Gleason score of 6 or less
  • Stages T1c to T2a prostate cancer

For men with a life expectancy greater than 15 years, the cancer should be in only one or two cores and constitute less than half of those cores. Other institutions say that patients with T2b or T2c cancer can pursue active surveillance.

If you and your doctor decide to proceed with active surveillance a careful follow-up protocol should be set up which includes regular PSA checks and follow-up biopsies. To qualify, traditionally the criteria is Gleason 3+3=6, small volume disease (less than 3 cores positive) and PSA less than 10. 

Every newly diagnosed man over 60 with prostate cancer should know about active surveillance. Prostate cancer typically grows very slowly. Men should know that, for the vast majority of patients, it is usually very safe to be followed closely for a number of years without treatment. Furthermore, men should know that, even in the best of hands, at least 40 percent of men who are treated with surgery or radiation will have some side effects, usually affecting their sexual or urinary health.

Carefully monitoring the cancer and delaying treatment until and if disease progression occurs is called "active surveillance," an option particularly well suited for men with low-risk prostate cancer, elderly men or men who have other serious health conditions.

The key to active surveillance is being carefully watched and monitored.

With active surveillance of prostate cancer, a man is followed very closely over time using prostate-specific antigen (PSA) as a marker for tumor activity. In addition, regular tissue sampling is done via biopsy to see if the tumor changes in any way. If there is a change in those parameters, the man is referred for therapy with radiation or surgery.

Active surveillance is a safe, evidence-based strategy to manage prostate cancer if done in a systematic fashion. It does allow a man to avoid the risks of treatment while preserving his option to seek a cure if it seems necessary at some point. Imaging technology can make active surveillance even safer as a strategy for a man with prostate cancer.

The criteria for active surveillance of prostate cancer include having low-risk or maybe intermediate-risk prostate cancer, which is partially defined by a man’s Gleason score. Doctors also look at prostate-specific antigen (PSA) level. Most programs have a PSA of 10 or less as a criteria for entry. In addition, doctors use tumor volume and a physical exam as criteria for active surveillance of prostate cancer.

One risk of active surveillance of prostate cancer is anxiety. Some men aren't comfortable with the idea of watching and waiting with cancer. Stress-reduction techniques can mitigate this, and doctors try to provide reassurance with regular biopsies and prostate-specific antigen (PSA) testing.

If you’re on active surveillance of prostate cancer, there may be reasons to seek treatment. Some centers will recommend treatment based on the rate of change in your prostate-specific antigen (PSA) level. Some centers don't look at that because PSA can rise for a variety of reasons, including benign growth of tissue. The other reason to seek treatment after being on active surveillance is an increase in your Gleason score.

There are several reasons doctors may stop active surveillance of prostate cancer. Active surveillance may be stopped when a man's prostate-specific antigen (PSA) level rises or if the Gleason score on a repeat biopsy gets worse. Doctors might also stop active surveillance if there's a change in the rectal exam or if a person just tires of the routine of surveillance.

Active surveillance is the concept of watchful waiting, which basically means that you’re probably going to die from something else before you die from prostate cancer, so we’re going to leave the cancer alone.

Prostate cancer typically occurs in older men, so active surveillance is a very reasonable thing to do. The active surveillance studies that were initially done on older men were advanced to younger men who were more likely to live 10 years or longer. The concept was that many of those men, with the advent of the PSA test, were being diagnosed with low-grade, low-volume disease. And we think that this is less likely to ever impact your life, even if you live another 10, 15, or 20 years. So rather than rushing to treat, which may have complications, we’re watching these patients. They get digital rectal examinations every three months, PSA tests, and periodic biopsies. The idea is that most men who have this early, low-grade stage of prostate cancer won’t need treatment, but by watching closely we can identify the patients who do need treatment while the cancer is still curable.

Following is the criteria for the active surveillance program:

  • You have an early stage of prostate cancer—T1c or T2a.
  • Less than 3 cores out of 12 cores are positive for prostate cancer, and no one core has more than 50 percent cancer.
  • The Gleason score is less than 6.

So to be a candidate for active surveillance, you have got to have the least aggressive prostate cancer.

The main reason for leaving an active surveillance program is anxiety.

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Important: This content reflects information from various individuals and organizations and may offer alternative or opposing points of view. It should not be used for medical advice, diagnosis or treatment. As always, you should consult with your healthcare provider about your specific health needs.