What Is Active Surveillance?

Active surveillance and watchful waiting are treatment approaches that involve making the decision not to immediately treat prostate cancer. Many healthcare providers employ these approaches for localized prostate cancer or prostate cancer that is slow-growing upon diagnosis.

Understanding the terminology

Active surveillance and watchful waiting are typically utilized in older men who have a greater chance of dying from another condition, or even from the natural aging process, before their prostate cancer becomes a major threat. Although a large proportion of men undergoing active surveillance and watchful waiting are older, these approaches can also be used in younger men with prostate cancer in certain situations.^1,2

Depending on your healthcare provider and their opinion on watchful waiting or active surveillance, these terms may be used interchangeably. For other doctors, these may be used as separate options that depend on how frequently, or infrequently, they want you to be monitored for cancer progression. Your doctor will be able to define these terms and what your appointment schedule will look like. The term observation may also be used to indicate similar tactics.

What is active surveillance and watchful waiting?

Active surveillance and watchful waiting involve making the decision not to treat prostate cancer once it has been diagnosed. This treatment approach involves not actively treating the cancer until the time is determined to do so. Although the cancer isn’t being treated, the person being monitored will be closely followed, and regular tests will be performed.

If your provider does not use these two terms interchangeably, it’s often understood that active surveillance is more intensive follow-up than watchful waiting, with active surveillance typically meaning eventually trying to treat and cure the cancer if there are differences in test results. Watchful waiting can sometimes mean monitoring patient symptoms with the eventual goal of treating symptoms as opposed to curing the disease. However, depending on your doctor's explanation, the difference between the two may be very minor or non-existent. If your healthcare provider is recommending active surveillance or watchful waiting, discuss with your provider what that means for your case and your goals of care for prostate cancer.

Typically, a person undergoing active surveillance visits their doctor regularly and receives a PSA test roughly once every 6 months. They may also receive a digital rectal exam (DRE) once a year. However, it’s important to note that these guidelines are not set in stone and can be adjusted based on your specific situation, and how closely your doctor believes you should be monitored. Another issue may be how often you receive repeat biopsies. Since biopsies for prostate cancer can carry risks and are invasive, it may be recommended that you not have a repeat biopsy until other screening options indicate that the cancer may be spreading.^1,2

What are the benefits of active surveillance or watchful waiting?

Treating prostate cancer can be life-changing. Many of the side effects and risks of treatment, such as erectile dysfunction, urinary or bowel incontinence, and psychological effects, can take a major toll on men and impair their quality of life. Often, these treatment options are also expensive.³

With advancements in prostate cancer screening technologies and the increasing number of men getting screened at earlier ages, men are getting diagnosed with prostate cancer more frequently and at younger ages.⁴ In many of these cases, these men may not have noticed symptoms and may not face serious risk of prostate cancer-related mortality for years, or even decades. By treating at a young age, men should be aware that they can be dealing with life-changing side effects that could in some cases be delayed or avoided altogether.²

Older men, specifically men over the age of 75, are also at risk for the same treatment-related side effects that can negatively impact quality of life, however, instead of delaying these effects for a later time, they may be able to avoid them altogether. The older a man is at the time of his prostate cancer diagnosis, the more likely he is to have other comorbid conditions that, from a statistical perspective, are more likely to cause death compared to prostate cancer. In these cases, opting for aggressive treatment early on has the potential to lead to more concerns with quality of life during a man’s final years, without actually increasing his life expectancy.^1,5,6

How does cancer spread influence active surveillance and watchful waiting?

Of course, when discussing active surveillance and watchful waiting it is in relation to localized, slow-growing, and minimally aggressive prostate cancers. If a man’s prostate cancer is thought to have spread beyond the prostate or is aggressive in nature, active surveillance will generally not be considered the best option by your healthcare team. There are exceptions to this, especially if a man does not want to be treated or has other medical conditions that prevent treatment, but on the whole, active surveillance and watchful waiting are not recommended for advanced prostate cancer where there may be other treatment options.

It is important to note that watchful waiting or active surveillance can be stopped at any time and traditional prostate cancer treatment can be pursued if it’s what you want and have discussed with your healthcare provider. Typically, the move toward more aggressive treatment will be made when your healthcare team determines it is medically necessary. Your doctor may advise surgical, hormonal, or other treatment if a repeat biopsy contains cells with Gleason grades of 4 or 5, if a higher number of biopsy samples contain cancerous cells, or if each sample contains a greater number of cancerous cells.¹

What does the research say?

There is a limited amount of studies and research that has been performed regarding the long-term outcomes of watchful waiting or active surveillance. Overall, experts seem to agree that these options are underused, especially in the U.S. when prostate cancer is being detected much earlier than ever before. For less advanced prostate cancer, watchful waiting or active surveillance typically have less physical or financial costs than undergoing early treatment. This is particularly true the older a man gets. Additionally, in much of this research, watchful waiting and active surveillance have the potential to decrease or significantly delay negative quality-of-life impacts that can come as a result of traditional prostate cancer treatment and its side effects.^3-6

As far as the survival benefits of watchful waiting or active surveillance, this is an area that needs further investigation. Only medium-sized studies and simulation models using thousands of recorded real-life people who have had or currently have prostate cancer have been conducted to date. These studies indicate that there seems to be only a marginal increase in overall survival, if any at all, for those with localized or slow-growing prostate cancer who choose aggressive treatment right away compared to those who have opted for the less aggressive approaches of watchful waiting or active surveillance. Additionally, the overall quality of life may be better for those who wait to begin treatment or who never undergo treatment in certain situations.^7-9 Although these results are interesting, and point toward increasing the frequency of active surveillance or watchful waiting decisions, much more research needs to be completed.