Not all men diagnosed with localised prostate cancer will require radical treatment with surgery or radiotherapy. Few low grade, low volume prostate cancers will progress and many are considered benign. Active surveillance allows us to monitor these cancers closely with the intention to treat radically if there is evidence of progression. This prevents unnecessary treatment with unwanted side effects in many men.
With PSA testing becoming more widely available, more prostate cancers are being diagnosed than ever before. About half of these are low grade, low volume cancers that are unlikely to progress and are suitable for active surveillance.
Who is suitable for active surveillance?
To be suitable for active surveillance, you have to be fit enough and willing to have active treatment should the cancer show signs of progression. Otherwise there is no point in monitoring so closely.
The prostate cancer needs to fit the following criteria:
- PSA <10
- Gleason 6 (low grade) on biopsy
- Low volume on biopsy
- Low volume or undetectable on multiparametric prostate MRI
- Localised to the prostate
What does active surveillance involve?
Initially, the prostate cancer has to be diagnosed and staged with a prostate biopsyand a multiparametric prostate MRI. If the criteria for suitability are satisfied, then the following surveillance will be performed:
- PSA test every 3 months (for 2 years)
- PSA test every 6 months thereafter
- Digital rectal examination every 6 months
- Prostate biopsy and MRI at 12 months
- Prostate biopsy and MRI every 2-3 years thereafter
How do I know if the cancer has progressed and I need radical treatment?
We would recommend radical treatment with any of the following signs of progression:
- Rapidly rising PSA
- Gleason 7 or greater on follow up biopsy
- Increase in the amount of cancer at biopsy
- Increase in tumour volume on prostate MRI
What are the chances of my prostate cancer progressing whilst on active surveillance?
In men aged 50 – 70 years who have met the above selection criteria, approximately one in four (25%) will progress and require radical treatment.
What are the disadvantages of active surveillance?
There are some disadvantages to undergoing active surveillance, but these need to be weighed up against the reasonable probability of avoiding radical treatment altogether.
- Some men find the diagnosis of cancer distressing and worry about “doing nothing”. About one in ten men will opt for radical treatment despite no progression of the cancer for this reason
- The follow up schedule is rigorous with multiple biopsies and scans
- There is the possibility of a worse outcome in delayed surgery or radiotherapy in the few men who do progress significantly
Can I “miss the boat” with my prostate cancer?
Yes, this is possible but highly unlikely. In the longest series of follow up in active surveillance patients by Professor Laurence Klotz’s group in Toronto, only 2 out of 299 patients (0.7%) on active surveillance died of prostate cancer.
Can I still have active surveillance if I have Gleason 7 prostate cancer?
The short answer is yes, but we would be cautious in recommending this to patients under 70 years of age. There is data to show this is safe in patients over 70 (who have a shorter life expectancy) but we do not have long term data to support this in younger patients. This makes it difficult to recommend as a good option in younger patients.
In the following video, Professor Laurence Klotz discusses the concept of active surveillance for low grade prostate cancer. Professor Klotz and his team from Sunnybrook Health Sciences Centre in Toronto were the first in the world to undertake large scale clinical studies in active surveillance. Most of what we know about outcomes from active surveillance come directly from his research.