Prostate Cancer Active Surveillance
Active surveillance for prostate cancer comprises regular checking of low-risk, localised tumours through tests and imaging. This approach helps lower side effects while ensuring timely intervention in case cancer advances.
Written by Dr Sonia Bhatt
Last updated on 3rd Jul, 2025
Prostate cancer is among the most common types of cancers affecting men. However, its types can vary. Based on the risk factors, not all types of prostate cancer demand quick treatment. Considering this, active surveillance emerges as an approach for managing low-risk, localised prostate cancer. This approach prioritises regular monitoring rather than immediate intervention.
This includes periodic tests, imaging, and biopsies to understand the stage of the cancer over time and then provide precautionary methods. Active surveillance helps reduce potential side effects and ensures prompt action. Not only that, it can also delay or avoid surgery or radiation treatments!
This blog offers information on prostate cancer, its active surveillance, advantages, challenges, and precautionary measures that can help individuals make informed decisions.
Criteria for Active Surveillance
Active surveillance is generally best suited for men with specific criteria that make this approach an effective one to manage prostate cancer. Such typical criteria include:
| Criteria | Description |
| Localised Cancer | Tumour is confined to the prostate and hasn’t spread |
| Slow Growth | Cancer is small and progresses gradually. |
| No Symptoms | No symptoms affecting daily life. |
| Underlying Health Problem | Advanced health issues like heart disease (something that can limit life expectancy) that could be worsened by the treatment. |
| Quality of Life | Priority is maintaining near-term quality of life over treatment. |
| Emotional Readiness | Comfortable living with monitored cancer without anxiety. |
| Long-Term Outlook | Longer life expectancy allows future curative treatment if needed. |
Monitoring Protocol
Prostate cancer needs to be continuously monitored. The monitoring process involves a series of tests to examine the progression of the cancer and to understand which tests are required. These tests include:
Digital Rectal Exam (DRE): The doctor examines the prostate by inserting a lubricated, gloved finger into the rectum to detect abnormalities in size, texture, or shape.
Prostate-Specific Antigen (PSA) Test: This is a blood test that measures PSA levels. Elevated PSA levels may indicate prostate issues such as infection, enlargement, or cancer.
Imaging Tests: Techniques like transrectal ultrasound or MRI create detailed prostate images. This helps identify abnormalities and guide further testing.
Prostate Biopsy: A thin needle collects prostate tissue samples for laboratory analysis to confirm the presence of cancer.
Cancer Aggressiveness Assessment:
Gleason Score: This score grades cancer cells from 6 (low grade) to 10 (high grade) based on their deviation from normal cells.
Genomic Testing: It analyses genetic mutations in cancer cells to provide insights into prognosis and treatment decisions.
Advantages of Active Surveillance
Active surveillance has many benefits and allows many men to avoid or delay aggressive cancer treatments while also maintaining quality of life:
Avoiding Unnecessary Treatment: Men with slow-growing cancer can often postpone or entirely avoid treatments like surgery or radiation, which may have significant side effects.
No Impact on Survival: Delaying treatment does not typically affect overall survival for men with low-risk prostate cancer.
Enhanced Monitoring Tools: Advances in imaging and molecular testing help doctors better assess who will benefit most from active surveillance, improving outcomes.
Lower Risk of Side Effects: By avoiding immediate treatment, men reduce the likelihood of experiencing complications such as incontinence or sexual dysfunction.
Challenges and Concerns
There are several challenges that come along with the diagnosis and treatment of prostate cancer. Here are some concerns:
1. Diagnostic Challenges
False Positives/Negatives: PSA tests and biopsies can misclassify cases, overdiagnosing insignificant cancers or missing aggressive ones due to sampling errors and cancer heterogeneity.
Imaging Limitations: Transrectal Ultrasound (TRUS) and conventional imaging techniques lack the accuracy to distinguish between benign and malignant tissues reliably.
2 Risk Stratification and Staging
Imprecise Staging: Current methods may fail to detect microscopic disease or accurately assess extracapsular extension, affecting treatment strategies.
Underused Active Surveillance: Suitable patients often do not opt for active surveillance due to insufficient monitoring tools and unclear protocols.
3. Monitoring Tumor Progression
Reliability of Imaging: Existing imaging tools are not always standardised or precise enough to track disease progression effectively.
Residual Disease Detection: Identifying microscopic residual cancer post-treatment remains challenging.
4. Response to Therapy
Bone Metastases Challenges: Imaging for bone metastases is often delayed due to reliance on osteoblastic activity (involves cells that create new bone).
Treatment Resistance: Advanced therapies are needed to address hormone-resistant prostate cancer and the progression of bone metastases.
5. Psychological Impact on Patients
Risk of Cancer Progression: Patients often face uncertainty about the risk of their cancer progressing, which can affect their treatment decisions and mental health.
Managing Anxiety and Expectations: Regular monitoring, while essential, may lead to heightened anxiety, fear of test results, and difficulty managing expectations, especially for patients under active surveillance.
Making the Decision
With a number of treatments available, choosing one prostate cancer treatment requires an informed approach to ensure the best outcomes -
Informed Decision-Making Process
Patients and providers collaborate to assess risks, benefits, and treatment options.
Shared decision-making improves outcomes and aligns care with patient preferences.
Role of the Healthcare Team
A multidisciplinary team offers guidance, medical expertise, and emotional support.
Personalised care ensures patients make informed choices.
Patient Education and Support
Clear education helps patients understand their condition and options.
Nurses and counsellors reduce anxiety and empower decision-making.
Transitioning from Active Surveillance
The transition from active surveillance to treatment for prostate cancer is guided by clear evidence of the progression of cancer -
Indicators for Transition:
Biopsy Results: Worsening biopsy findings that suggest increased tumour aggression.
PSA Levels: Rising prostate-specific antigen levels point to possible progression.
Imaging Changes: MRI scans reveal tumour growth or other concerning changes.
Age and Overall Health: Advancing age or other medical conditions influencing treatment suitability.
Available Treatment Options
Surgery: Radical prostatectomy as a curative approach.
Radiation Therapy: Non-surgical cancer treatment targeting affected areas.
Hormone Therapy: Androgen deprivation therapy for men opting to delay curative treatments.
Collaborative Decision-Making
Patients and their medical teams make a combined decision, considering medical findings, future priorities, and quality of life.
Recent Advances and Research
Prostate cancer research has led to significant advancements in diagnosis, treatment, and prevention, improving patient outcomes.
1. Genetics and Biomarkers
Gene studies help identify men at higher risk and determine cancer aggressiveness.
Biomarkers like PSA derivatives (PHI, IsoPSA), PCA3, and TMPRSS2:ERG aid in early detection and monitoring.
2. Imaging Innovations
PSMA PET-CT: Detects metastatic cancer more effectively than standard scans.
Multiparametric MRI (mpMRI): Offers detailed imaging for staging and guiding biopsies.
3. Treatment Breakthroughs
Targeted Therapies: PARP inhibitors (e.g., Olaparib, Rucaparib) address metastatic hormone-resistant prostate cancer.
Advanced Hormone Therapy: Drugs like Enzalutamide and Relugolix offer improved outcomes with fewer side effects.
Precision Surgery and Radiation: Robotic prostatectomy and image-guided radiotherapy enhance precision while reducing complications.
4. Emerging Treatments
Ablative Techniques: Cryotherapy, high-intensity focused ultrasound (HIFU), and laser ablation target early-stage or bone-spread cancers.
Immunotherapy: CAR T-cell therapy and vaccines like Sipuleucel-T are under study for advanced cases.
5. Prevention and Lifestyle
Nutritional compounds (e.g., lycopene, isoflavones) are being explored for cancer risk reduction.
Hormonal drugs, like 5-alpha reductase inhibitors, show promise in risk management.
6. Improved Diagnostics
Combined biopsy techniques (e.g., MRI/TRUS fusion-guided biopsy) improve accuracy.
Advanced blood tests like SelectMDx and My Prostate Score 2.0 refine risk assessment.
Conclusion
Active surveillance provides an effective strategy for managing low-risk, localised prostate cancer. It prioritises monitoring over immediate treatment to maintain quality of life.
With advancements in diagnostics, imaging, and personalised care, patients can make informed decisions based on individual needs. Emerging research in genetics, innovative therapies, and improved diagnostic tools continue to enhance prostate cancer management, offering hope for better outcomes.
Collaborating with healthcare teams and understanding their options can help patients confidently navigate their care, balancing timely intervention with maintaining long-term well-being.
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