If diagnosed with localized prostate cancer (cancer that has not spread to distant sites such as bones and lymph nodes), disease management can take many forms, depending on the risk category of disease. Patients with low-grade, slow-growing tumors confined to the prostate gland may consider active surveillance. This involves monitoring prostate cancer in its localized stage until the doctor feels that curative treatment is indicated; such a strategy allows patients to defer treatment (and any treatment-related side effects) until that time.

According to the American Society of Clinical Oncology, patients with low-risk, low-grade disease (a Gleason score of 3+3=6) should consider active surveillance. It is also be an option for some patients with a Gleason score of 3+4=7. Patients within these categories may choose to postpone prostate cancer treatment because of its associated risks and side effects.

Top Candidates for Active Surveillance

You may be a candidate for active surveillance if you meet the following qualifications:

• Your cancer appears to be confined to the prostate.

• Your tumor is small and is expected to grow slowly.

• You aren’t experiencing any significant symptoms.

• You have the ability to live with cancer without anxiety reducing your quality of life.

• You wish to maximize near-term quality of life while long-term risks of cancer progression are minimal.

• You have a relatively long life expectancy and may benefit from curative local therapy if your cancer progresses.

Men with localized prostate cancer that is unfavorable intermediate risk or higher and with a long life expectancy usually require local treatment. They are not good candidates for active surveillance.

When it comes to active surveillance, each patient should carefully weigh the potential decrease in quality of life with treatment against the possibility that the window of opportunity for cure will disappear without treatment.

Active Surveillance Testing Schedule

Medical experts offer various recommendations regarding frequency of testing and when to start treatment during active surveillance. We recommend the following periodic evaluations while under active surveillance for prostate cancer:

• A confirmatory prostate biopsy within 6-24 months of diagnosis to assure a disease state that is favorable for active surveillance

• PSA testing every three to six months

• Digital rectal examination (DRE) once a year

• Prostate MRI every 2-3 years

• Prostate biopsies every one to five years depending on the results of the above factors

If test results or symptoms indicate the cancer is progressing, treatment is recommended with curative intent.

Active Surveillance Results

We have followed over 2,000 men on active surveillance since 1995. The data we have gathered on these men helped make active surveillance a guideline supported recommendation from the National Comprehensive Cancer Network, the American Urological Association, the American Society of Clinical Oncology, and other international organizations.

We have followed our patients closely and are happy to report that surveillance has been very safe in our hands: The incidence of prostate cancer-specific mortality has been 0.1% (or one in a thousand) over 15 years, and with over 20 years of follow-up the risk of death from other causes was over 20 times more common. Approximately 50% of men go on to have curative therapy within 10 years of initiating active surveillance, with the majority doing so within the first 5 years. Nevertheless, we have some men who have shown no signs of their cancer progressing to a more dangerous state for more than 20 years.

Active Surveillance Recommendations

We recommend that men on surveillance follow-up with a visit at least once a year so that their provider can determine what tests will be needed over the coming year (eg. PSA, MRI, biopsy, etc). Your provider will also let you know about any active clinical trials in this area, new treatments, and updated recommendations for men on surveillance.

Based on evidence from our program and others, we currently recommend:

• A healthy diet as per the Dietary Guidelines for Americans (link) – we have shown this to be associated with a lower risk of prostate cancer progression. This diet is more plant-based that the typical American diet, with restrictions on salt and trans-fats for example, but nevertheless allows for modest intake of meat and dairy.
• An activity/exercise regimen, even if only minimal - we have noted an associated between a sedentary lifestyle and prostate cancer progression, so get out there!
• That you ask your provider about treatment for any urinary symptoms you might be experiencing – treating coexisting benign prostatic hyperplasia (BPH) if symptomatic should not prevent you from staying on active surveillance
• That you not take over-the-counter prostate supplements without checking with your Urology provider. These can lower PSA levels and mask prostate cancer-related changes, are costly, and have not shown to be helpful in preventing prostate cancer progression.

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