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Prostate Cancer: When Treatment Can Wait

Reviewed by Melinda Ratini, DO, MS on September 04, 2020

Prostate cancer can grow very slowly. In some men, it can grow so slowly they may never need treatment. But doctors still want to keep an eye on the cancer so they can take action if it gets worse. This approach is known as active surveillance or watchful waiting.

Your doctor may have suggested these options instead of other treatment for a few reasons:

  • Your age
  • Other health conditions you have, such as heart disease, diabetes, stroke, or other cancer
  • Risks and side effects of treatment
  • Your tumor is small
  • You don’t have symptoms

Some doctors say “active surveillance” or “watchful waiting” to mean the same thing: tracking the cancer and how it may or may not grow. Others think these terms are slightly different. If your doctor mentions either term, ask them exactly what they mean by it.

Who Can Use Active Surveillance?

Active surveillance may be an option if your cancer:

  • Is small
  • Is only in your prostate
  • Has a prostate-specific antigen (PSA) level less than 10 ng/mL
  • Has a Gleason score of 7 or less, which means your cancer is slow-growing. A pathologist (a doctor who studies cells and tissue) will look closely at your tumor biopsy to get your Gleason score.
  • Could be treated with surgery or radiation if it starts to grow

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You must also:

  • Not have any symptoms
  • Feel OK about waiting to see if your cancer grows. (You’re in charge of all your treatment decisions.)
  • Be able to go about your day-to-day life and not worry that your cancer will spread
  • Understand the benefits and risks of your decision to follow active surveillance

How It Works

Active surveillance keeps a close watch on your tumor to see if it starts to grow. Your doctor will tell you what tests you need and how often you need to have them. It’s very important that you not miss any of these tests.

Many doctors use guidelines from the American Society of Clinical Oncology. They recommend:

  • A prostate-specific antigen (PSA) blood test every 3 to 6 months to see if your PSA level has gone up, which could mean that your cancer has grown
  • A digital rectal exam (DRE) at least once a year so your doctor can feel for new bumps or hard spots on your prostate
  • A follow-up biopsy 6 to 12 months after your prostate cancer diagnosis to check on the tumor’s growth
  • A biopsy every 2 to 5 years to see if the cancer cells have started to grow more quickly

If your doctor sees signs that your tumor has grown, they will talk to you about whether it’s time to stop active surveillance and start treatment.

What to Consider

A risk of active surveillance is that it can give the cancer a chance to grow or spread. That can limit your options for treatment later. But if the cancer is growing, it will probably be caught and treated. For many men, this never happens, so they don't have any potential consequences of unnecessary treatment.

The younger you are, the less likely it is that your doctor will recommend this approach. Even though the tumor is growing slowly, it can still give you problems 20 or 30 years from now.

What Research Shows

Only a few studies have compared active surveillance to treatment. They have found that men with slow-growing tumors who choose active surveillance are likely to live as long after their prostate cancer diagnosis as men with slow-growing tumors who have surgery or radiation right away.

Who Might Use Watchful Waiting?

Doctors usually recommend watchful waiting for men who are older or who have other serious health problems. With watchful waiting, there are fewer tests. Instead, your doctor will watch to see if you get any prostate cancer symptoms. If you do, you and your doctor will talk about next steps. This could be treatments for the cancer. Or it could be treatments that will control the symptoms. The decision will be based on your age and other health problems.

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Your doctor may suggest this method if:

  • You have other health conditions that could make treatment too hard to handle.
  • The prostate cancer probably won’t cause you any problems in your lifetime.

If you have symptoms, you and your doctor can decide at that time whether you need treatment.

Risks of Treatment

The decision to go with active surveillance or watchful waiting is a personal one. But your doctor will discuss these options with you, because treatments such as surgery, radiation, or chemotherapy can be rough on your body. In some cases, the risks and side effects of these treatments are more severe than the benefits of killing the cancer. Impotence and urinary incontinence are two such side effects.

Making Your Decision

Some men prefer to have regular tests to see if their cancer grows than to start treatment. They don’t feel like they will worry all the time that their cancer has grown. And they want to try to avoid treatment-related side effects, if they can.

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On the other hand, some men don’t want to live with a cancer that might be growing, and they want to start treatment right away. They feel like they would worry too much if they didn’t start treatment. And they don’t want to have to go to the doctor for regular tests.

You’ll want to weigh the pros and cons and see what you’re most comfortable with. There is no “right” way to think about these choices. The best choice is the one that is right for you. And no matter what approach you take, you’re in charge of your treatment decisions.

WebMD Medical Reference

Sources

SOURCES:

American Society of Clinical Oncology: “Prostate-Specific Antigen (PSA) Testing for Prostate Cancer Screening."

American Cancer Society: “Expectant management, watchful waiting, and active surveillance for prostate cancer,” “Observation or Active Surveillance for Prostate Cancer,” “Tests to Diagnose and Treat Prostate Cancer,” “Surgery for Prostate Cancer,” “Radiation Therapy for Prostate Cancer.”

Prostate Cancer Foundation: “Living With Prostate Cancer: Active Surveillance.”

American Urological Association: “Guideline for the Management of Clinical Localized Prostate Cancer (2007).”

American College of Radiology and Radiological Society of North America: “Magnetic Resonance Imaging (MRI) -- Prostate.”

New York University Langone Medical Center: “Active Surveillance or Watchful Waiting.”

Prostate Cancer UK. “Choosing a Treatment: Active Surveillance.”

Johns Hopkins Medicine: “Active Surveillance for Prostate Cancer,” “When to Treat Versus When to Watch.”

InformedHealth.org: “Prostate Cancer Overview.”

Memorial Sloan Kettering Cancer Center: “Active Surveillance for Prostate Cancer.”

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