Active surveillance is a way to treat low-risk prostate cancer that doesn't pose an immediate risk to your well-being. If you choose active surveillance, your cancer will be closely monitored for any changes that would warrant more active treatment. You'll have regular checkups, prostate biopsies, and blood tests to measure prostate-specific antigen (PSA) levels. Over the years, active surveillance has emerged from a research concept to the preferred standard of care for most low-risk prostate cancer.
Active Surveillance for Prostate Cancer
Who may benefit
The ideal candidate for active surveillance has:
- A PSA at the time of diagnosis of 10 ng/mL or less that does not change much over time. A better way to interpret risk using PSA is to calculate PSA density, or PSAD (PSA divided by prostate volume). A PSA density under 0.15 is favorable, suggesting the cancer is unlikely to grow.
- Ultrasound, MRI, digital rectal exam or other test results suggesting the cancer has not spread outside the prostate gland.
- Biopsy results that indicate a low-risk cancer, including a Gleason score of 6 or less (no pattern 4 or 5). However, it is important that the biopsy was performed correctly, with enough samples taken to confirm that the cancer isn't large or aggressive. If the initial biopsy wasn't performed at a high-volume center and wasn't image-guided, another biopsy is usually warranted before finalizing a decision for active surveillance. These confirmatory biopsies are particularly important if the original biopsy was done outside an academic setting. An MRI is recommended before the biopsy to help target the tissues to sample.
Active surveillance may also be an option for some patients with slightly higher risk cancers (such as those with a low-volume Gleason score of 3+4), especially if imaging or genomic testing results are reassuring.
Some men with risk factors, such as a family history of cancer and genetic mutations, may still choose active surveillance but may need a more intensive surveillance regimen to identify any early signs of disease progression. African American men, who seem to have an elevated risk for disease progression, may also require closer monitoring.
What to expect
If you choose active surveillance, you'll see your doctor for regular checkups. During these visits, you'll undergo tests to detect any changes in your cancer. The tests usually include:
- A blood test every six months to measure PSA levels
- Genetic testing of the tumor and other tests that help assess risk and the appropriateness of continuing active surveillance
- Repeat MRI scans or prostate biopsies (or both) every one to two years initially (sometimes sooner than one year) and then less frequently to monitor your cancer grade and volume
If the tests suggest your cancer is growing or becoming more aggressive, your doctor may recommend you have treatments, such as surgery or radiation therapy, or move up the date for your next biopsy. But if changes are small or nonexistent, your doctor may advise that you can safely continue active surveillance.
As part of treatment, you doctor may also recommend lifestyle changes, such as improving your nutrition, reducing stress and getting more exercise. A UCSF study showed that patients on active surveillance who made lifestyle changes had lower PSA levels and lower treatment rates than those who didn't make these changes. You may find it helpful to join a support group or participate in a study on the impact of nutrition, exercise and other lifestyle factors. Consistently making healthy choices can also lower your risk of cardiovascular disease – the number one cause of death in men with or without prostate cancer.
There are some risks associated with active surveillance. They include a low risk of infection with every biopsy and a very low risk of cancer progressing in any one interval of surveillance. Sometimes men choose active surveillance for a period of time and then decide to undergo treatment.
Thousands of UCSF patients have chosen active surveillance to initially manage their prostate cancer. This is one of the largest groups of patients on active surveillance in the world. About one-third of these men receive treatments, such as surgery or radiation, within five years of diagnosis and 50% within 10 years. The window of opportunity to cure a prostate cancer is usually years or even decades. Outcomes for men who choose active surveillance after diagnosis are similar to the expected outcomes if they had chosen surgery or radiation right away. Based on our experience and data from other centers, the risk of significant cancer progression in the short to intermediate term, while not zero, appears to be very low.
Your doctor can answer any questions you have about active surveillance. Together, you can decide whether this is a good option for you.