Active surveillance

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Overview

As surprising as it may seem, in some cases, if your cancer is confined within the prostate, your doctor may recommend waiting before you start treatment.

What is watchful waiting?

Older men or men diagnosed with a slow-growing cancer who are suffering from other more life-threatening diseases will die before cancer poses a threat.

When all signs indicate the cancer is slow-growing, the selected course of action may be to wait for symptoms to appear before beginning treatment.

This is called watchful waiting. It is important to weigh the inconvenience of treatment with the risks posed by the cancer on a case by case basis.

What is active surveillance?

Active surveillance is a way to monitor a slow-growing prostate cancer instead of treating it right away. The goal is to avoid unnecessary treatments or delay treatment and its possible side effects. 

How do you explain this?

Prostate cancer is often slow-growing and can be present for many years and never spread, produce symptoms, or threaten the life of a patient.

Active surveillance can be a treatment option if you are diagnosed with a prostate cancer that has a very low risk of progressing.

What is active surveillance?

Active surveillance means the healthcare team watches you closely. Treatment is given if your tumour shows signs of growing or if your cancer shows signs of an increased risk of progression.

The term active surveillance gives you the impression that nothing is happening which is not necessarily the case. This is an active method based on closely monitoring your cancer’s progression.

Who can undergo active surveillance?

Active surveillance may be recommended if you are in good health—regardless of your age—if your cancer is still in its early stages, and if it is at a low grade where it grows slowly. In this way, risks of erectile dysfunction and incontinence associated with this treatment can at least be temporarily avoided.

Choice-justifications

Reasons for choosing active surveillance

Choosing observation depends on a number of factors such as your general health, your age, and your family history. If your doctor feels that your death will be caused by a condition other than prostate cancer, he may recommend observation as your preferred choice of treatment.

This option is also dependent on how aggressive your cancer is. Well-differentiated, low-risk cancers are generally less aggressive and develop more slowly.

Thus, you may be offered active surveillance if:

  • the cancer is low grade with a Gleason score of 6 or less
  • the cancer is intermediate grade with a Gleason score of 7 and it hasn’t spread outside of the prostate
  • the prostate-specific antigen (PSA) level is less than 10 ng/mL
  • the cancer isn’t causing any symptoms
  • you prefer not to have treatment right away so you can avoid treatment-related side effects and keep the quality of life that you’re used to
  • you are older or have severe medical problems, so your life expectancy is less than 10 years

Advantages and limitations

Avantages of active surveillance

  • No treatment side effects
  • No change to your quality of life
  • Beneficial for patients with a limited life expectancy

Limitations of active surveillance

  • Risk of spread
  • Risk of missing your chance to be cured
  • Frequent follow-up visits and tests
  • Induces stress and anxiety in many patients
  • Deferred treatment can be complex and cause more adverse effects
  • Nerve preservation may be more difficult after delayed surgery
  • Risk of progression or metastasis

Risks and complications

Although active surveillance is not a treatment in itself, there can still be risks. The disease can start to grow more quickly than anticipated and can reach an incurable stage before the doctor has a chance to react. This doesn’t happen often, but you should be aware of the risk—and of the fact that there is no 100 percent reliable tool for predicting the progression of the disease. 

What to expect

Regular tests

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Regular tests will be done about every 3–6 months to monitor your prostate cancer. This can vary depending on your situation.

  • Prostate-specific antigen (PSA) test
  • Physical examination, including a digital rectal exam (DRE)
  • Prostate biopsy
  • Bone scan, chest x-ray, or CT scan, depending on signs and symptoms
  • Prostate MRI (in some cases)

Treatment if necessary

If your cancer is growing more quickly than expected or changes grades, your doctor may recommend active treatment (radical prostatectomy, radiation therapy, and/or hormone therapy).

Around 25–30% of men under active surveillance end up having to undergo treatment because of signs of cancer growth. 

Emotions you may feel

It is normal to worry about your cancer growing and spreading faster than expected. Some men may find it too stressful to have their prostate cancer watched or monitored without active treatment. For these men, immediate therapy may be the preferred option. If you have concerns, talk to your doctor.

What you can do

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Think about your values

Most men with low-risk prostate cancer have time to think about their choices. These tips may help you reach a decision.

Discuss these questions with your spouse or partner:

  • Do I want to get rid of my cancer, even if I might have sexual or urinary problems?
  • Which side effects would upset me most?
  • Would I be okay with active surveillance, even if I am worried and have to see the doctor more often?

Review your health history

Give your cancer care team your full personal and family medical histories.

  • Ask how your age and general health could affect treatment
  • Ask if you have any condition that might increase the risks of treatment, for example, conditions such as diabetes, heart problems, or bowel disease might increase your risk of sexual, urinary, or bowel problems.

Learn

Find out all of your treatment options

Ask your doctors about each choice, including benefits and side effects. Some doctors only suggest the option they know best. Typically:

  • a radiation oncologist can discuss active surveillance and radiation treatment.
  • a urologist can discuss active surveillance and surgery.

Talk about your choices with these physicians and your family doctor.

We are here for you

Our urology healthcare professionals are there to listen, support and answer questions from patients, their families, the general public and healthcare professionals. Feel free to contact them.

Also take the time to visit each of our pages on this website, as well as our YouTube channel, in order to get familiar with the disease, with our expert lectures, our section on available resources, the support that is offered to you, our events and ways to get involve to advance the cause.

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