Active Surveillance? Watchful Waiting? What Every Man With Prostate Cancer Should Know

August 23, 2016
Oleksandr N. Kryvenko, MD, FCAP

Oleksandr N. Kryvenko, MD, FCAP, is Assistant Professor of Pathology and Urology at the Sylvester Comprehensive Cancer Center, University of Miami Health System, in Miami, FL.

There’s a member of your health care team who plays a vital role in your diagnosis and cancer care who you may never meet face to face: the pathologist. This is the doctor who analyzes the sample of tissue removed during a biopsy to make the correct diagnosis.

As a pathologist specializing in prostate cancer, I know that any cancer diagnosis is alarming. Men diagnosed with prostate cancer may be even more alarmed if active surveillance and watchful waiting come up. Their very names sound like the opposite of what should be done in cancer treatment. But understanding these 2 approaches—and their differences—can help you make informed decisions as you consider prostate cancer treatment plans.

What’s the concept behind active surveillance and watchful waiting?

The 2 approaches emerged over the last 25 years as options for some men with prostate cancer. These options are based on extensive medical research that shows many men diagnosed with early-stage, low-grade prostate cancer need little if any immediate medical treatment. This is particularly true for older men.

The reality is that 97% of men with prostate cancer will not die from the disease.

So what exactly is active surveillance?

Active surveillance means that instead of getting immediate treatment, a patient regularly visits his doctor for exams, prostate-specific antigen (PSA) tests, and periodic prostate biopsies. Generally, the doctor repeats PSA blood tests about every 6 months. Also, digital rectal exams and prostate biopsies are done once every 12 months. With active surveillance, patients can avoid the potentially harmful side effects from treatments such as surgery, radiation therapy, and hormone therapy.

If a repeat biopsy shows that the cancer has spread to more prostate tissue or resulted in a higher biopsy Gleason score, then men who are on active surveillance may have to discuss new treatment options with their doctor.

How is watchful waiting different?

Watchful waiting tends to be used for older men who are not expected to live for a long time. An example might be an elderly man who has localized, low-risk prostate cancer and other chronic and potentially life-threatening illnesses. In cases like this, the doctor doesn’t treat the cancer. Instead, the focus is on managing the illnesses that pose an immediate threat to life and quality of life. Patients who choose watchful waiting may have an occasional PSA blood test, but not repeat prostate biopsies. 

How do doctors know who’s a good candidate for active surveillance?

Pathologists on the cancer care team are critical to determining whether active surveillance is a good fit for individual patients. Pathologists report specific details that help determine whether the approach is a safe alternative to immediate treatment. The approach may be an option if a patient has a:

  • PSA density (blood PSA level ÷ by prostate volume) of less than 0.15

  • Low volume of localized cancer

  • Biopsy Gleason score of 3+3=6 (Grade Group 1)

Doctors also take into account other factors, including the cancer’s stage and the patient’s age, health, family history, and personal preference. A patient’s race and ethnicity are also important factors. Recent clinical studies found that PSA levels and tumor size among black men with prostate cancer vary distinctly from those among white men with prostate cancer.

In other words, the doctor and the patient make a joint decision based on the information the pathologist provides and a patient’s individual factors.

What’s the bottom line?

When active surveillance is an option, it reduces overtreatment and side effects, which helps maintain a man’s health, including sexual health. share on twitter In general, men receiving active surveillance have an excellent prognosis even if their cancer later progresses and requires treatment. For frail or elderly patients with low-risk prostate cancer, watchful waiting may be considered to preserve quality of life.


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