What You Need to Know
Prostate cancer is the second most common cancer in men worldwide, with over 1.4 million cases diagnosed each year. While many men with prostate cancer undergo surgery, radiation therapy, or other treatments, there is growing recognition that not all men with prostate cancer need immediate treatment. For some men, active surveillance may be a better option.
Active surveillance, also known as active monitoring, is a prostate cancer treatment approach that involves regular monitoring of the cancer with the goal of detecting any changes or progression early. Unlike watchful waiting, which is typically recommended for older men with early-stage prostate cancer, active surveillance is typically recommended for men with low-risk prostate cancer who are otherwise healthy and have a long-life expectancy.
This has been recommended by guidelines from major organizations like Cancer Care Ontario,(1) ASCO, (2) the UK, (3) and EAU, which also endorse AS in selective favorable-intermediate risk patients.
With recommendations from USPTF on PSA screening, the number of men diagnosed with prostate cancer, especially those in the low-risk group, has almost doubled in the last 2 decades. (4)
The American Urological Association has launched the AQUA Registry in 2013 as a means to measure, report, and improve healthcare quality and patient outcomes. It includes a total of 1945 urology practitioners, representing 349 practices in 48 US states and territories. (5)
The AQUA Registry comprised more than 8.5 million unique patients, including 298,081 ever treated for prostate cancer from January 1, 2014, to June 1, 2021. Out of these, 20,809 low risk men with known primary treatment were noted. Data on this large prospective cohort study showed increased number of men on AS from the year 2014-2021 (25% vs 60 %). A declining trend from 77% to 40% in men undergoing active treatment has been noted. Out of these 20,809 men on AS, 30.1% have undergone RP from 2014-2021 and 16% men underwent RP in the year 2020 alone. 2.6% underwent brachytherapy, 27% underwent radiation, 5.75% underwent ADT monotherapy from 2014-2021. To sum up of all patients on active surveillance almost 70% will require some form of intervention within 7 years.
How Active Surveillance Works
If you and your doctor determine that active surveillance is the best option for you, you will undergo regular monitoring to ensure that any changes or progression of your cancer are detected early. This typically involves the following:
- PSA Testing: Prostate-specific antigen (PSA) is a protein produced by the prostate gland. Elevated levels of PSA in the blood can be a sign of prostate cancer. You will undergo regular PSA testing to monitor any changes in your PSA levels.
- Digital Rectal Exam: Your doctor will perform a digital rectal exam (DRE) to check for any changes in the size, shape, or texture of your prostate.
- Imaging Studies: Depending on your individual situation, your doctor may recommend imaging studies such as an MRI or ultrasound to evaluate your prostate.
- Biopsies: Your doctor may recommend periodic biopsies to evaluate your prostate tissue and detect any changes or progression of your cancer.
The frequency of monitoring will depend on your individual situation and the recommendations of your doctor. Typically, monitoring will occur every 3 to 6 months.
If there are any changes or progression of your cancer, your doctor may recommend further testing or treatment. This may include repeat biopsies, imaging studies, or treatment such as surgery or radiation therapy.
Why Consider Active Surveillance? – Balancing the Risks and Benefits
Like any prostate cancer treatment, active surveillance has its own risks and benefits that must be discussed with your doctor.
There are several reasons why active surveillance may be a good option for some men with prostate cancer:
- Avoiding the Side Effects of Treatment: While prostate cancer treatments can be effective, they can also cause side effects such as urinary incontinence, erectile dysfunction, and bowel problems. For some men, the risk of these side effects may outweigh the potential benefits of treatment.
- Preserving Quality of Life: Treatment for prostate cancer can be stressful and disruptive, and it can interfere with daily activities and relationships. Active surveillance allows men to continue living their lives without the added stress of treatment.
- Avoiding Overtreatment: Not all prostate cancers are aggressive or life-threatening. In fact, many prostate cancers grow very slowly and may not cause any symptoms or health problems during a man’s lifetime. Active surveillance allows men with low-risk prostate cancer to avoid unnecessary treatment and the associated risks and costs.
- Potentially Delaying Treatment: For some men, active surveillance may delay the need for treatment, allowing them to avoid treatment until it is absolutely necessary.
Risks:
- Progression of cancer: While low-risk prostate cancer may grow slowly, it can still progress and become more aggressive over time. Active surveillance increases the risk of missing a window for successful curative treatment.
- Delayed treatment: Delaying treatment may allow the cancer to spread to nearby tissues or other parts of the body, potentially making it more difficult to treat.
- Anxiety: Living with the knowledge of cancer can cause emotional distress and anxiety for some men leading to the term “Anxious Surveillance” by some authorities.
- 4. Repeat biopsies: Frequent biopsies can be uncomfortable and carry risks of infection, bleeding, and other complications with surgery. Increasing biopsies distort the peri-prostatic fascial anatomy, leading to difficult nerve preservation. This may increase the risk of erectile dysfunction after surgery. (6)
- Uncertainty: The uncertainty of not knowing whether or when to start treatment can be stressful for some men and their families.
It is important to discuss the risks and benefits of active surveillance with your doctor to determine whether it’s a suitable option for your individual situation. In some cases, other treatment options, such as surgery or radiation therapy, may be recommended instead of active surveillance. Choosing an experienced Robotic Surgeon with a proven track record of successful outcomes will go a long way in mitigating most of the potential side effects associated with surgery.
- Morash C, Tey R, Agbassi C, Klotz L, McGowan T, Srigley J, et al. Active surveillance for the management of localized prostate cancer: Guideline recommendations. Can Urol Assoc J. 2015;9(5-6):171-8.
- Chin J, Rumble RB, Kollmeier M, Heath E, Efstathiou J, Dorff T, et al. Brachytherapy for Patients With Prostate Cancer: American Society of Clinical Oncology/Cancer Care Ontario Joint Guideline Update. J Clin Oncol. 2017;35(15):1737-43.
- Sanda MG, Cadeddu JA, Kirkby E, Chen RC, Crispino T, Fontanarosa J, et al. Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline. Part II: Recommended Approaches and Details of Specific Care Options. J Urol. 2018;199(4):990-7.
- Carroll PR. USPTF Prostate Cancer Screening Recommendations-A Step in the Right Direction. JAMA Surg. 2018;153(8):701-2.
- Cooperberg MR, Meeks W, Fang R, Gaylis FD, Catalona WJ, Makarov DV. Time Trends and Variation in the Use of Active Surveillance for Management of Low-risk Prostate Cancer in the US. JAMA Netw Open. 2023;6(3):e231439.
- Sooriakumaran P, Calaway A, Sagalovich D, Roy S, Srivastava A, Joneja J, et al. The impact of multiple biopsies on outcomes of nerve-sparing robotic-assisted radical prostatectomy. Int J Impot Res. 2012;24(4):161-4.