Active Surveillance

Of the top 10 most common cancers, prostate cancer is the only cancer where many patients, over 30%, have a slow-growing tumour that does not warrant immediate aggressive treatment. The cancer will grow so slowly, if at all, that a man will die of something else before the cancer causes any symptoms. Active Surveillance (sometimes called Active Monitoring) is now the primary option for men that have a low-risk prostate cancer that is unlikely to cause harm or decrease life expectancy. It is a better choice than immediate radical treatment such as surgery or radiation as it is a pro-active method which monitors men with early prostate cancer or who do not need immediate curative treatment. This spares them the side-effects that may be caused by a treatment which may later prove to have been unnecessary. It is now the first-line approach for men found to have low-grade prostate cancer. Results suggest that many men on Active Surveillance will never need to be treated for their prostate cancer.

Men on Active Surveillance are closely monitored by their consultant. They would typically have an initial multi-parametric MRI scan, repeated every 1-2 years, and a six-monthly or annual PSA blood test. A repeat biopsy may only be needed if the MRI scan reveals any significant change. Those cases that show signs of tumour progression will be advised to receive curative treatment, normally with surgery, radiotherapy or brachytherapy, dependent on age and other factors.

     Advantages and disadvantages


Active Surveillance may avoid unnecessary treatment with its resultant side effects.

    • MRI scans now reduce any risks associated with TRUS biopsies.

    • It may also give the opportunity for a change of diet and lifestyle which may help in keeping the cancer under control.

But:

    • It can create on-going worry about ‘having cancer’ and ‘doing nothing’.

    • It could happen that the ‘window of opportunity’ for curative treatment may be missed should the cancer unexpectedly become more aggressive.

A change of lifestyle?

Increasingly, research shows that lifestyle changes can reduce the side effects of treatment and slow the growth of some tumours and reduce the risk of relapse. This means that you could benefit from lifestyle changes during Active Surveillance. Smokers should start by giving up and those of us that drink should ensure we consume no more than recommended levels. Regular exercise and, for many of us, changes to diet can be beneficial. See Exercise, Diet and Lifestyle for more details.

Monitoring your PSA

PSA velocity (the rate at which the PSA increases) and doubling time (the period over which the PSA number doubles), together with other factors (e.g. mpMRIs), play an important part in any Active Surveillance programme, so it is important that you keep a careful record of your PSA results. You have the right, in co-operation with your consultant, to opt out of Active Surveillance and be treated at any stage.

If a man does choose Active Surveillance the NICE guideline recommends the protocol in the table below:

  Active Surveillance protocol  
  Timing Tests
  Year 1 of active surveillance. Every 3 to 4 months: measure PSA
Monitor PSA kinetics (PSA density and velocity)
At 12 months: DRE (digital rectal examination)
At 12 to 18 months: multiparametric MRI
  Year 2 onwards Every 6 months measure PSA
Monitor PSA kinetics (PSA density and velocity)
Every 12 months: DRE (digital rectal examination)
  Note: If clinical or PSA changes of concern arise during Active Surveillance, mpMRI and/or biopsy may be repeated.

This table has been assembled from information in Table 4 of NICE guideline ‘Prostate cancer: diagnosis and management’ published 9 May 2019.


Men with ‘low risk’ cancer are
the ideal
candidate for Active Surveillance


Exam
ple: Low volume cancer – Stage 1c;
Gleason 6; PSA less than
10ng/ml