What is active surveillance?
Active surveillance is a structured monitoring programme for prostate cancer that is small, slow growing and confined to the prostate. Many of these cancers would never cause harm during a man's lifetime. Treating them straight away with surgery or radiotherapy brings a risk of urinary leakage and erectile problems, often with no gain in survival.
It is not the same as doing nothing. The aim is to pick up the minority of cancers that do change while there is still every chance of cure, and to spare everyone else the side effects of treatment they did not need.
NICE guidance (NG131) recommends offering active surveillance to men with low risk localised prostate cancer (Cambridge Prognostic Group 1), and considering it for men in Cambridge Prognostic Group 2. Read the NICE guideline
Who is it suitable for?
Suitability depends on your biopsy result, PSA level, MRI scan and your own priorities. Active surveillance is usually appropriate when:
- The biopsy shows Gleason 3+3=6 (Grade Group 1), or in selected men Gleason 3+4=7 with only a small amount of pattern 4
- The PSA is below 10 ng/mL, or below 20 in selected cases
- The MRI shows the cancer is confined to the prostate
- You would be fit enough for curative treatment later, if it were ever needed
UK specialists group localised prostate cancer into five Cambridge Prognostic Groups (CPG). Your group is one of the main factors in deciding whether monitoring or treatment is the better choice.
| Group | Typical features | Usual approach |
|---|---|---|
| CPG 1 | Gleason 6 (Grade Group 1), PSA below 10, confined to the prostate | Active surveillance offered |
| CPG 2 | Gleason 3+4 (Grade Group 2) or PSA 10 to 20, confined to the prostate | Active surveillance or treatment, after discussion |
| CPG 3 | Gleason 4+3 (Grade Group 3), or Gleason 3+4 with PSA 10 to 20 | Treatment usually recommended |
| CPG 4 and 5 | Higher grade, PSA above 20, or spread beyond the prostate capsule | Treatment recommended |
Personal preference matters too. Some men find regular tests reassuring; others would rather have treatment and move on. Both are reasonable, and Mr Ameen will talk you through the trade offs honestly.
What does monitoring involve?
The schedule below follows the NICE protocol. Your own plan may be adjusted to your results.
First year: PSA every 3 to 4 months
A simple blood test, with the trend in your PSA (how quickly it changes) tracked over time rather than any single result. An examination of the prostate at around 12 months.
Repeat MRI at 12 to 18 months
A follow up MRI scan is compared with your original scan to confirm the cancer is stable.
From year two: PSA every 6 months
If things are stable, PSA tests become less frequent, with an examination once a year.
Further MRI or biopsy only if needed
A repeat scan or targeted biopsy is arranged if the PSA rises significantly, the examination changes, or the MRI shows a new or growing area.
Clear review at every stage
Mr Ameen reviews each result with you and agrees the plan for the next stage, so you always know what happens next.
How safe is it? What the evidence shows
The strongest evidence comes from the UK ProtecT trial, which randomly assigned men with PSA detected prostate cancer to monitoring, surgery or radiotherapy and followed them for 15 years.
Survival was the same whichever option men chose. Cancer spread was more common in the monitoring group, and many monitored men did go on to have treatment. It is worth knowing that ProtecT monitoring relied mainly on PSA tests and included men with higher risk cancers. Modern active surveillance is more precise: it is reserved for lower risk cancers and uses MRI scans and clear thresholds for moving to treatment.
When is treatment recommended?
Moving from surveillance to treatment is not a failure. It is the programme doing its job. Treatment is usually recommended if:
- A repeat biopsy shows a higher grade of cancer, or more of it
- The MRI shows the cancer has grown or a new area has appeared
- The PSA rises steadily and significantly
- You decide you would prefer to have treatment
The main curative options are robotic radical prostatectomy and radiotherapy. Because the cancer has been watched closely, most men who switch to treatment still have an excellent chance of cure.
Living with active surveillance
- Keep active and maintain a healthy weight; this benefits your general and heart health
- Stop smoking if you smoke
- Keep to your PSA and scan schedule; missed tests are the main risk of the approach
- Tell us about any new urinary symptoms, bone pain or blood in your urine
- Feeling anxious is normal. If worry is affecting your life, say so; changing plan is always an option
Frequently asked questions
No. Active surveillance is for men who would be suitable for curative treatment, and it aims to cure the cancer if it ever changes. Watchful waiting is for men for whom curative treatment is not appropriate, often because of age or other health problems, and focuses on controlling symptoms with fewer tests.
Low risk prostate cancer rarely spreads, and the monitoring schedule is designed to pick up any change early. In the ProtecT trial survival was the same whether men were monitored or treated, and modern surveillance uses MRI to watch the cancer more closely than was possible then.
Yes. Surveillance is an option, not an obligation. Mr Ameen will explain the benefits and side effects of each approach so you can make the choice that is right for you.
Yes. You can bring your existing PSA results, MRI scan and biopsy report to a private consultation for a second opinion and a clear monitoring or treatment plan.
Usually at 12 to 18 months after diagnosis, and after that if your PSA or examination changes. Some men have scans at regular intervals depending on their risk.