Because prostate cancer often grows very slowly, some men (especially those who are older or have other serious health problems) may never need treatment for their prostate cancer. Instead, their doctors may recommend approaches known as expectant management, "watchful waiting," or active surveillance. Until recently, watchful waiting usually meant waiting until the cancer was causing symptoms before starting any treatment. Now, it is more common to watch the patient closely with regular PSA tests, rectal exams, and ultrasounds to see if the cancer is growing. If the cancer does seem to be growing or getting worse, treatment may be recommended. Some doctors still consider this to be watchful waiting, while others consider this different from watchful waiting and call it "active surveillance." Not every doctor means the same thing when they say "watchful waiting," so it is important to ask your doctor what he or she means if they use this term. Either of these approaches may be recommended if your cancer is not causing any symptoms, is expected to grow very slowly, and is small and contained within one area of the prostate.

Neither of these approaches is likely to be a good option if you are young, healthy, and/or have a fast-growing cancer (for example, a high Gleason score).

At this time, active surveillance is a reasonable option for some men with slow-growing cancers because it is not known whether treating the cancer with surgery or radiation will actually help them live longer. These treatments have definite risks and side effects that may outweigh the possible benefits for some men. Some men are not comfortable with this approach, and are willing to accept the possible side effects of active treatments in order to try to remove or destroy the cancer.

With active surveillance, your cancer will be carefully monitored. Usually this approach includes a doctor visit with a PSA blood test and digital rectal examination (DRE) about every 3 to 6 months. Transrectal ultrasound-guided prostate biopsies may be done every year as well. Treatment is started if the cancer seems to be growing or getting worse, based on either a rising PSA, a change in the rectal exam, or biopsy results. On biopsies, an increase in the Gleason score or extent of tumor (based on the number of biopsies containing tumor) are both signals to start treatment. This treatment usually involves surgery or radiation therapy. Active surveillance allows the patient to be observed for a time, only treating those men who have a serious form of the cancer. This allows men with a less serious cancer avoid the side effects of treatment that may not have helped them live longer. A possible downside of this approach is that there's a chance it could allow to become more advanced. This could limit your treatment options such as surgery.

Right now, not all experts agree how often testing should occur for active surveillance. There is also debate about when is the best time to start therapy. Still, several early studies have shown that men who choose active surveillance and go on to be treated do just as well as those who decide to start treatment right away. Hopefully we will have a better idea of the pros and cons of active surveillance versus active treatment in the near future. A large study sponsored by the National Cancer Institute and the Veterans Affairs Cooperative Studies Program is now looking into how active treatment affects survival and quality of life of prostate cancer patients of different ages. The PIVOT (short for Prostatic Intervention Versus Observation Trial) is still in progress. There are also studies underway to determine the best approach for monitoring patients on active surveillance which should shed more light on this issue.

Last Medical Review: 07/30/2009
Last Revised: 07/30/2009