Active surveillance for prostate cancer
Many patients are diagnosed with prostate cancer that is unlikely to affect them during their lifetime, even young men with many decades of life expectancy. Because treatment can cause significant side effects, active surveillance has become the preferred approach for suitable patients with low-risk prostate cancer.
Mr Philip Dundee specialises in the diagnosis and management of prostate cancer and offers active surveillance to appropriately selected patients.
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What is active surveillance?
Active surveillance involves closely monitoring prostate cancer without immediate treatment when the risk of metastatic progression is low.
The aim is to avoid or delay the potential side effects of surgery, radiation or focal therapy while continuing to monitor for changes that may indicate more aggressive cancer behaviour and the need for treatment.
Key points:
- Most low-risk prostate cancers do not require treatment
- Active surveillance avoids unnecessary side effects while maintaining the opportunity for cure if the case changes
- Careful follow-up with PSA, MRI and occasional biopsy is essential
Who is suitable for active surveillance?
Almost all patients diagnosed with low-risk prostate cancer are suitable for active surveillance. This generally includes patients with:
- PSA level below 10 ng/mL
- ISUP Grade Group 1 (Gleason 3+3=6) prostate cancer
- Localised disease
For these patients, active surveillance is generally preferred to immediate treatment with surgery, radiation or focal therapy.
Some patients with favourable intermediate-risk prostate cancer may also be suitable for active surveillance. This may include selected patients with a PSA above 10ng/mL and/or Gleason 3+4=7, ISUP Grade Group 2 prostate cancer.
These patients have a higher long-term risk of progression than those with low-risk disease, so careful selection is important. Factors that influence suitability include:
- whether the cancer is visible on MRI
- the volume and extent of cancer on biopsy
- the amount of Gleason pattern 4 disease
- PSA level and PSA behaviour over time
- age, general health and personal preferences
PSMA PET may also provide additional information in selected patients with favourable intermediate-risk disease, although its precise role in active surveillance is currently investigational.
What does active surveillance involve?
Active surveillance usually involves regular PSA testing, interval MRI scans and occasional repeat prostate biopsy.
The exact schedule is tailored to the individual patient and depends on the grade and volume of cancer, MRI findings and changes in PSA over time.
In patients with stable low-risk disease, MRI may sometimes be repeated every three to four years. More frequent imaging may be appropriate for patients with favourable intermediate-risk disease, a rising PSA or other features suggesting possible progression.
In Mr Dundee’s practice, repeat biopsy in patients with low-risk disease is generally reserved for those with evidence of progression on MRI or, less commonly, concerning changes in PSA. Patients with favourable intermediate-risk prostate cancer may require repeat biopsy more frequently, depending on their individual disease features.
Is it risky not to treat prostate cancer?
Patients with low-risk prostate cancer rarely develop metastatic disease, making active surveillance a very safe strategy for appropriately selected patients.
Patients with favourable intermediate-risk prostate cancer generally have a low risk of metastatic progression in the short term, but their risk may be higher over the medium to long term. Careful evaluation, counselling and ongoing monitoring are therefore essential.
Once prostate cancer has spread beyond the prostate, it is generally no longer curable, although many effective treatments remain available. The purpose of active surveillance is to identify signs of more aggressive disease early enough for curative treatment to be offered when appropriate.
A small number of patients may develop metastatic disease while on active surveillance. This is uncommon, particularly in patients whose PSA, MRI and other clinical findings remain stable.
