Active surveillance is a cancer management strategy involving the close, structured monitoring of a localized, low-risk tumor instead of immediate surgery or radiation. The goal is to avoid the potential side effects of definitive treatments, such as urinary or sexual dysfunction. This strategy maintains the option to intervene with curative intent if the disease shows signs of progression. Active surveillance is currently considered the preferred course of action for many patients diagnosed with very low- or low-risk localized cancers.
Active Surveillance vs. Watchful Waiting
Active surveillance is a rigorous, proactive program intended to treat the cancer curatively if monitoring tests detect a change in the disease’s risk profile. It is offered to healthier patients who have a longer life expectancy and whose cancer is considered low-risk.
Watchful waiting is a less intensive approach focused on managing symptoms as they arise, without frequent, scheduled tests. This strategy is reserved for older patients or those with serious coexisting health conditions where life expectancy is limited. The treatment offered is usually palliative, aimed at controlling the cancer’s effects rather than eliminating the disease entirely.
The Standard Monitoring Protocol
Active surveillance relies on a strictly defined schedule of diagnostic tests. A key component is the prostate-specific antigen (PSA) blood test, typically measured every three to six months to track biochemical changes. A digital rectal examination (DRE) is often performed annually to check for physical changes in the gland.
Imaging techniques, particularly multi-parametric magnetic resonance imaging (mpMRI), play a significant role in modern active surveillance protocols. An mpMRI may be performed at the start of surveillance to confirm eligibility by ruling out undetected, higher-grade tumors. It is then repeated every one to three years to monitor for changes in tumor size or location, which helps guide the decision for follow-up testing.
Prostate biopsies are used to accurately assess the cancer’s grade and volume over time. A confirmatory biopsy is often performed within six to twenty-four months of the initial diagnosis to ensure the cancer was not initially underestimated. Subsequent surveillance biopsies are then conducted, typically every one to five years, depending on the overall risk profile and the results of the PSA and MRI assessments.
Criteria for Escalation to Definitive Treatment
Escalation to definitive treatment is triggered by specific clinical findings indicating cancer progression. Pathological progression, detected during a repeat biopsy, is a common reason. This is often marked by an increase in the Gleason score or Grade Group, such as a change from a Gleason score of 6 to a score of 7 or higher.
Progression is also defined by an increase in the physical volume of the tumor, identified by a greater number of positive tissue cores or a higher percentage of cancer involvement. Biochemical progression, indicated by changes in tumor markers, also serves as a trigger. This includes a rapid rise in the PSA level or a PSA doubling time of less than three years.
If progression is observed, the window of opportunity for a curative outcome is still open, and the patient transitions to active therapy like surgery or radiation. Although many patients eventually transition to active treatment, this delay allows them to avoid treatment side effects for years, or even indefinitely. This strategy does not compromise their long-term survival.
Navigating the Emotional Burden
Active surveillance can impose a substantial emotional and psychological burden. Many patients grapple with the persistent anxiety of living with a known, untreated cancer diagnosis, often described as feeling like a “ticking time bomb.” This uncertainty can lead to higher rates of anxiety and depression.
A common manifestation of this emotional toll is “scanxiety,” the heightened fear and stress experienced around scheduled monitoring appointments and test results. This continuous cycle of testing and waiting can result in surveillance fatigue, where the mental exhaustion of monitoring overshadows the physical relief of avoiding treatment side effects.
Managing this emotional complexity is an important part of the overall care plan. Open communication with the health care team regarding the psychological impact is strongly encouraged. Many patients find comfort and resilience by connecting with support groups to share experiences and coping strategies.