Active Surveillance for Prostate Cancer

At a glance

• What it is: Active surveillance is a structured way of managing prostate cancer without immediate surgery or radiotherapy. The cancer is monitored with PSA tests, clinical review, multiparametric MRI and repeat biopsy, with treatment offered if the cancer shows signs of becoming more significant.^1,2,7,8,9
• Who it suits: Men with low-risk prostate cancer, and selected men with favourable intermediate-risk disease, where the cancer appears small-volume, confined to the prostate and biologically slow-growing.^7,8,9,10
• How it differs from watchful waiting: Active surveillance is not "doing nothing". It is a curative-intent monitoring program. Watchful waiting is a less intensive palliative strategy used when treatment would only be started to control symptoms.^7,8,9
• What the evidence shows: Large active-surveillance cohorts show very low prostate-cancer mortality at long follow-up in carefully selected men, while a defined proportion later switch to treatment because the cancer grade, MRI appearance, PSA pattern or personal preference changes.^2,4,5,6
• Where Urology NSW sits: Dr Raji Kooner discusses active surveillance with men whose biopsy, MRI, PSA and general health make it a reasonable option, alongside the alternatives of robotic prostatectomy, radiotherapy, brachytherapy and focal therapy.

What is active surveillance?

Active surveillance is a planned follow-up program for prostate cancer that appears unlikely to cause harm in the short to medium term. Instead of moving straight to surgery or radiotherapy, the cancer is watched carefully and treatment is reserved for the point at which the cancer changes or the patient no longer feels comfortable with monitoring.^1,2,7,8,9

The approach exists because not all prostate cancers behave the same way. Some prostate cancers grow slowly for many years and may never cause symptoms or shorten life, particularly in older men or in men with small-volume, low-grade disease. Treating every low-risk cancer immediately can expose men to urinary, sexual and bowel side effects without a clear survival advantage for that individual.^1,3,7

Active surveillance tries to balance two aims: avoid or delay treatment side effects when the cancer is quiet, while still keeping the option of curative treatment open if the cancer becomes more aggressive.

How is active surveillance different from watchful waiting?

The terms are sometimes used loosely, but they mean different things in modern prostate cancer care:

• Active surveillance is for men who could still have curative treatment if needed. It includes scheduled PSA testing, clinical review, MRI and repeat biopsy. Treatment is triggered by evidence that the cancer has become more significant.^7,8,9
• Watchful waiting is usually used for men whose age, frailty or other health problems mean curative treatment is unlikely to help. Follow-up is less intensive, and treatment is usually started only if symptoms develop.

For that reason, active surveillance should not be understood as "leaving the cancer alone". The word active matters.

Who is suitable?

Suitability is based on the whole picture: PSA, digital rectal examination, multiparametric MRI, biopsy grade, number and length of involved biopsy cores, family history, age, general health and the patient's priorities.

Active surveillance is most often considered for:

• ISUP Grade Group 1 prostate cancer (Gleason 3+3 = 6), particularly when only a small amount of cancer is found on biopsy.^7,8,9
• Selected favourable Grade Group 2 cancer (Gleason 3+4 = 7), where the pattern 4 component is small, MRI is reassuring, and there are no adverse features such as cribriform or intraductal carcinoma.^7,8,9,10
• PSA usually less than 10 ng/mL, or a PSA density that is reassuring once prostate volume has been measured.^7,8,9
• Clinical stage T1c or T2a, meaning the cancer is not felt or is only a small nodule on one side of the prostate.^7,8,9
• Reassuring MRI findings, for example no large PI-RADS 4 or 5 lesion and no radiological sign of cancer extending outside the prostate.^11,12
• Men whose personal priority is to preserve urinary, sexual and bowel quality of life, provided they understand the need for repeated testing and the possibility of later treatment.

Active surveillance is usually not the right choice for:

• High-risk or very-high-risk prostate cancer.
• Unfavourable intermediate-risk disease, high-volume Grade Group 2 disease, or any Grade Group 3 or higher disease unless there are exceptional reasons.
• MRI or examination findings suggesting extracapsular extension, seminal vesicle involvement or lymph-node spread.
• Men who are unlikely to attend follow-up, or who would find the psychological burden of monitoring unacceptable.

What the evidence shows

Long-term active-surveillance cohorts

The Toronto active-surveillance cohort reported long follow-up in men with favourable-risk prostate cancer. At 15 years, prostate-cancer-specific mortality remained low, but not zero, and metastases occurred in a small minority - especially where disease was reclassified as higher risk during follow-up.² The Johns Hopkins active-surveillance program also reported durable outcomes in carefully selected favourable-risk men, with treatment offered when repeat biopsy or clinical findings changed.⁴

These cohorts support active surveillance as a mainstream option for low-risk prostate cancer, provided selection is careful and follow-up is not allowed to drift.

The ProtecT trial and active monitoring

The ProtecT randomised trial compared active monitoring, radical prostatectomy and radiotherapy in men with PSA-detected localised prostate cancer. At 15 years, prostate-cancer mortality was low in all three groups, but metastases and clinical progression were more common in the active-monitoring group than in the surgery or radiotherapy groups.³

ProtecT is important, but it should be interpreted carefully. The monitoring arm was less intensive than many modern active-surveillance programs because it began before routine multiparametric MRI and MRI-targeted biopsy became standard. Even so, it illustrates the central trade-off: monitoring can avoid or delay treatment side effects, but it requires acceptance of a higher chance of needing treatment later.

How many men eventually need treatment?

Across published active-surveillance programs, a substantial minority of men eventually switch to surgery, radiotherapy, focal therapy or another active treatment. The reason may be biopsy upgrading, MRI progression, PSA change, a change in clinical examination, or a personal decision that ongoing monitoring is no longer acceptable.^1,2,4,5,6

The important point is that conversion to treatment is not automatically a failure of surveillance. It is one of the planned outcomes of surveillance: treatment is started when the risk profile changes.

Where the evidence is not yet definitive

• Surveillance protocols vary between centres. The exact timing of PSA tests, MRI and repeat biopsy is adjusted to the individual patient and to the quality of the initial MRI and biopsy.^6,7,8,9
• Selected Grade Group 2 surveillance is now recognised in guidelines, but the margin for error is narrower than for Grade Group 1 disease. Men in this group need especially careful counselling and follow-up.^7,8,9,10
• Multiparametric MRI has reduced unnecessary repeat biopsy in some settings, but MRI cannot replace biopsy in every case. A negative or stable MRI does not guarantee that the cancer grade is unchanged.^11,12,13
• The psychological burden of living with an untreated cancer varies widely between men and is not fully captured by PSA, MRI or biopsy results.

How monitoring is usually done

A surveillance schedule is personalised, but it usually includes:

• PSA blood tests, often every 3 to 6 months in the first few years, then spaced out if the pattern is stable.^7,8,9
• Clinical review and digital rectal examination, usually every 6 to 12 months, depending on risk and symptoms.^7,8,9
• Multiparametric MRI, particularly at baseline if it has not already been done, and again if PSA kinetics or previous MRI findings justify it.^11,12,13
• Confirmatory biopsy, commonly within the first 12 months after diagnosis if the initial sampling may have missed higher-grade disease, then repeated at intervals or sooner if PSA or MRI changes.^7,8,9,13
• Review of general health and preference, because the right balance can change as a man gets older, develops other health issues, or feels differently about surveillance.

Dr Kooner commonly reviews the original pathology, MRI and biopsy details before confirming that surveillance is appropriate. If the original biopsy was transrectal or did not target a suspicious MRI lesion, a repeat transperineal MRI-fusion biopsy may be recommended before committing to long-term surveillance.

Dr Kooner's active surveillance protocol usually involves regular PSA testing, a repeat prostate MRI scan between year 1 and year 3, and a repeat prostate biopsy somewhere between year 1 and year 5, depending on patient and tumour factors.

What can trigger treatment?

Treatment is considered if there is evidence that the cancer is no longer behaving like low-risk disease, or if the patient no longer wishes to continue monitoring.

• Biopsy upgrading, for example Grade Group 1 becoming Grade Group 2 with a meaningful pattern 4 component, or any move to Grade Group 3 or higher.
• Increasing cancer volume, such as more biopsy cores involved or longer cancer length within cores.
• MRI progression, including a growing lesion, a new PI-RADS 4 or 5 lesion, or concern for extension beyond the prostate.^11,12,13
• PSA change, especially a sustained rise or increasing PSA density that is not explained by benign enlargement, prostatitis, recent ejaculation, cycling or instrumentation.
• Change on examination, such as a new or enlarging palpable abnormality.
• Patient preference, including anxiety or a change in priorities after discussion of the trade-offs.

If treatment becomes appropriate, the options are revisited in the same way as for a new diagnosis: robotic radical prostatectomy, radiotherapy, brachytherapy, focal therapy in selected cases, or systemic therapy where the disease biology requires it.

Benefits and trade-offs

The main benefit of active surveillance is that it can avoid or delay treatment and its side effects in men whose cancer may never have harmed them. This can preserve urinary control, erections, ejaculation, bowel function and general quality of life for as long as surveillance remains appropriate.^1,2,3,4

The trade-offs are real:

• Cancer progression can occur. The risk is low in carefully selected men, but it is not zero.^2,3,4
• Repeated testing is required. PSA tests, MRI scans and biopsies are part of the program, not optional extras.
• Biopsy has risks. Bleeding, infection, urinary retention and discomfort can occur, even with modern transperineal technique.^7,8,9
• Living with known cancer can be stressful. Some men sleep well on surveillance; others find the uncertainty difficult and choose treatment for that reason.
• Later surgery may be technically more complex in some cases, particularly after multiple biopsies or inflammation, although this is only one factor in the decision.

Active surveillance at Urology NSW

Active surveillance is one of the standard prostate cancer pathways discussed at Urology NSW. It sits alongside robotic radical prostatectomy, single-port robotic surgery, radiotherapy, brachytherapy, NanoKnife / IRE focal therapy and other treatment options.

The recommendation is based on the individual cancer and the individual patient. For one man, surveillance may be the most sensible first step. For another man with the same PSA but a different MRI, biopsy pattern, family history or anxiety level, early treatment may be more appropriate.

Patients who have been advised to have immediate treatment, or who are unsure whether surveillance is appropriate for their situation, can request a second opinion. The review usually focuses on the original pathology report, MRI images and report, PSA history, biopsy method and the patient's priorities.

Frequently asked questions

Is active surveillance the same as doing nothing?

No. Active surveillance is a structured follow-up program with defined tests and defined triggers for treatment. It is different from watchful waiting, which is less intensive and usually used when curative treatment is not planned.^7,8,9

Can active surveillance miss the chance to cure the cancer?

In carefully selected men, the risk is low, but it is not zero. That is why surveillance requires MRI, repeat biopsy where indicated, and regular review. If the cancer grade, volume or MRI appearance changes, treatment is reconsidered while curative options may still be available.^2,3,4,7,8

How often will I need PSA tests?

Many protocols use PSA every 3 to 6 months in the first few years, then every 6 to 12 months if stable. The exact schedule depends on the risk group, PSA density, MRI findings and biopsy history.^7,8,9

Can MRI replace repeat biopsy?

Sometimes MRI can reduce the need for biopsy, especially when MRI quality is high and the PSA pattern is stable. It does not replace biopsy in every case. MRI can miss some higher-grade disease, so biopsy is still recommended when there is uncertainty or a trigger for re-sampling.^11,12,13

What if I become anxious on surveillance?

Anxiety is a valid reason to revisit the plan. Some men feel reassured by structured follow-up; others find the uncertainty too much. The decision can be changed after discussion of the risks and benefits of treatment.

Can younger men choose active surveillance?

Yes, selected younger men with low-risk disease may choose surveillance to preserve quality of life. The follow-up needs to be rigorous because younger men have a longer period over which the cancer could change.

What treatment would I have if surveillance stops?

The treatment depends on the reason surveillance stops. Options may include robotic radical prostatectomy, radiotherapy, brachytherapy, focal therapy in selected cases, or systemic therapy for more advanced disease. The decision is made after fresh staging and review of the current biopsy and MRI.