What is active surveillance?

Active surveillance is a way of monitoring localised (early) prostate cancer, rather than treating it straight away. You might hear it called active monitoring.

If you go on active surveillance, you’ll have regular tests to check on the cancer. You won’t have any treatment unless these tests show that your cancer may be growing, or you decide you want treatment – so you’ll avoid or delay the side effects of treatment. If there are signs your cancer may be growing, you’ll be offered treatment that aims to cure your cancer.

It might seem strange not to have treatment, but localised prostate cancer often grows slowly – if at all – and may have a low risk of spreading. So it may never cause you any problems or affect how long you live. Many men on active surveillance will never need treatment.

Active surveillance isn’t the same as watchful waiting, which is a different way of monitoring prostate cancer. Read about the differences between active surveillance and watchful waiting.

Watch Robin's story for one man's experience of being on active surveillance:

Who can go on active surveillance?

What are the advantages and disadvantages?

Deciding whether or not to go on active surveillance is a personal choice. What may be important to one person might not be to someone else. If you’re offered active surveillance, there’s usually no rush to make a decision. Speak to your doctor or nurse before deciding whether it’s right for you.

Advantages

• As you won’t have treatment while you’re on active surveillance, you’ll avoid the side effects of treatment.
• Active surveillance won’t affect your everyday life as much as treatment might.
• If tests show that your cancer might be growing, there are treatments available that aim to cure your cancer.

Disadvantages

• You might need to have more prostate biopsies which can cause side effects, and which some men find uncomfortable or painful.
• Your cancer might grow more quickly than expected and become harder to treat – but this is very uncommon.
• Your general health could change, which might make some treatments unsuitable for you if you did need them.
• Some men may worry about not having treatment, and about their cancer growing – but you can change your mind and have treatment instead if this is a problem.

What does active surveillance involve?

You’ll have regular tests to monitor your cancer. The tests aim to find any changes that suggest the cancer is growing. Depending on your hospital, you may have:

• PSA tests
• MRI scans
• digital rectal examinations (DRE)
• prostate biopsies

If your test results show that your cancer might be growing, you will be offered further tests to check on the cancer. If any changes are found, you can have treatment that aims to get rid of the cancer.

PSA test

This is a blood test that measures the amount of prostate specific antigen in your blood. It's a useful test for monitoring prostate cancer. If your PSA level rises faster than expected, this could be a sign that your cancer is growing.

Your doctor may use your PSA level to work out the following:

• PSA velocity – how quickly your PSA level is rising. It is usually recorded as the change in your PSA level per year. For example, if your PSA level has increased from 3 to 4 over the last 12 months, your PSA velocity would be 1ng/ml/year.
• PSA doubling time – the time it takes for your PSA level to double. For example, if your PSA level has increased from 3 to 6 in one year, your PSA doubling time would be 1 year.
• PSA density – your PSA level in relation to the size of your prostate. For this you will have an ultrasound or an MRI scan to measure the size of your prostate. Your PSA density is then worked out by dividing your PSA level by the volume (size) of your prostate.

If your doctor is concerned by any of these test results, they might recommend an MRI scan or a prostate biopsy to check if the cancer is growing.

Read more about the PSA test.

Booking your PSA test

Depending on your hospital, you may have your PSA tests at your local hospital, or you may need to book these tests yourself at your GP surgery. Check with your doctor how often and where you should book your PSA tests. Give yourself plenty of time to book them, as hospitals and GP surgeries can be very busy and you may not be able to get an appointment straight away.

MRI scan

You should have an MRI scan when you first go on active surveillance to make sure your cancer hasn’t spread outside the prostate. You may then have regular MRI scans, although this will depend on your hospital. Your doctor may also suggest having an MRI scan if your PSA test or DRE results suggest your cancer might be growing. The scan can help your doctor decide if you need a biopsy. Read more about MRI scans.

Digital rectal examination (DRE)

This is where the doctor feels your prostate through the wall of the back passage (rectum). A normal prostate should feel soft and smooth. Your doctor will feel your prostate for any changes, such as hard or lumpy areas, that could suggest the cancer is growing. Read more about having a DRE.

Prostate biopsy

Once you start active surveillance, you may only have another biopsy if other tests suggest your cancer is growing. Your PSA level might rise a little, even if your cancer isn’t growing. Your doctor will decide if it has risen enough for you to need a biopsy.

If you do have a biopsy that shows your cancer has grown, then your doctor may recommend you have treatment. This treatment will usually aim to get rid of the cancer. Read more about prostate biopsies.

How often will I have tests?

The tests you have, and how often you have them, will depend on your hospital. The following is an example, but your doctor will tell you how often you will have tests.

First year of active surveillance

• A PSA test every three to four months
• A DRE after 12 months
• An MRI scan after 12 to 18 months.

Second year onwards

• A PSA test every six months
• A DRE every 12 months.

Will I need treatment in the future?

If the results of the tests show your cancer is growing, you’ll be offered treatment that aims to get rid of the cancer – for example, surgery or radiotherapy.

You can decide to have treatment at any time, no matter how long you have been on active surveillance. Some men decide they want to have treatment even though there are no signs of any changes. If you decide you do want treatment, speak to your doctor or nurse.

Is active surveillance safe?

Research shows active surveillance is a safe way for men with low risk prostate cancer to avoid or delay unnecessary treatment. And you have the same chances of living for 10 years or more as you would if you chose to have treatment with surgery or radiotherapy.

Changes to your cancer

There’s a chance that your cancer could grow. But the risk of it growing without being picked up is very low. And the tests used to monitor your cancer should find any changes early enough to treat it.

There is a very small chance that the cancer will spread outside your prostate before being picked up, and treatment might not be able to get rid of it completely.

This can happen if:

• the tests used in active surveillance miss changes in your cancer, or
• the tests used to diagnose your prostate cancer didn’t find some areas of faster-growing cancer.

But this is very uncommon. And you’ll have regular tests to check on the cancer and make sure it isn’t growing. Talk to your doctor or nurse if you’re worried about the risk of your cancer growing.

Are there any side effects?

As you won’t have treatment while you’re on active surveillance, you won't get any of the side effects of treatment.

You might need to have prostate biopsies while you’re on active surveillance though, and these can cause some short-term side effects. But many hospitals now do MRI scans instead of regular prostate biopsies.

How is active surveillance different from watchful waiting?

Active surveillance is often confused with watchful waiting, which is another way of monitoring prostate cancer. Some people use names such as ‘active monitoring’ and ‘wait and see’ to describe both active surveillance and watchful waiting. These can mean different things to different people, so ask your doctor or nurse to explain exactly what they mean.

The aim of both is to avoid having unnecessary treatment, but the reasons for having them are different.

Active surveillance

• It’s suitable for some men with localised prostate cancer, who can still have treatment that aims to cure their cancer.
• If you need treatment in the future, it will aim to cure your cancer.
• It involves more regular hospital tests than watchful waiting, such as prostate specific antigen (PSA) tests, magnetic resonance imaging (MRI) scans and prostate biopsies.

Watchful waiting

• It’s generally suitable for men with other health problems who may be less able to cope with treatments such as surgery or radiotherapy, or if treatment would cause more problems than the cancer itself.
• If you do have treatment in the future, it will aim to control the cancer and manage any symptoms, rather than aim to cure it.
• It can be used in men with localised prostate cancer, or in men whose cancer has spread to other parts of the body (locally advanced or advanced prostate cancer).
• It involves fewer tests than active surveillance, but the cancer will still be monitored. These check-ups usually take place at the GP surgery rather than at the hospital.

Questions to ask your doctor or nurse

You may find it helpful to take a list of any questions you have to your next appointment.

• Am I going on active surveillance or watchful waiting?
• How often will I have my PSA level checked?
• Who will be in charge of booking my PSA tests?
• Who will check my PSA level and give me the results?
• How often will I see my doctor or nurse?
• Will I have other regular tests or scans? If so, which ones and how often?
• What test results would lead you to recommend treatment? Are there any specific results that mean I should have further tests?
• What treatments could I have if my cancer grows?
• What can I do to improve my general health?

References

Updated: April 2019 | Due for Review: April 2021