Prostate Cancer: Active Surveillance or Treatment?

By Kathleen Doheny. Medically reviewed by Tom Iarocci, MD. May 7th 2016

Roughly 1 in 6 men in the United States will be diagnosed with prostate cancer in their lifetimes, translating to more than 200,000 new cases per year.

For most men, the reaction to a diagnosis of prostate cancer is fear, anxiety and a sense of urgency, says Louis Kavoussi, M.D., chair of urology at the North Shore-Long Island Jewish (LIJ) Health System.

“They know someone who has died of cancer, and all these evil images pop up in their heads,” he says. Most patients want treatment ASAP, and they often figure that means surgery, perhaps followed by chemotherapy or radiation.


Such aggressive treatment is recommended in some cases, but for many, a more measured approach is advised. Because cancer of the prostate often grows slowly, treatment may not be necessary. In fact, most men will die with prostate cancer, not from it, says Kavoussi, who is also professor of urology at the Hofstra North Shore-LIJ School of Medicine at Hofstra University.

The idea of avoiding unnecessary aggressive treatment isn’t new. For years, doctors have suggested that some men with prostate cancer can delay getting treatment because their cancer appears to be small and slow-growing, and it isn’t expected to cause problems in their lifetime. Instead of treatment, doctors closely monitor the cancer. The idea of treatment is considered only if the cancer appears to be growing and spreading. Formerly called “watchful waiting,” this approach is now commonly referred to as “active surveillance,” which Kavoussi says is a more accurate description.


New research supports active surveillance

New research gives even more weight to the idea that active surveillance is better for some men. If a prostate tumor is of a low grade when first diagnosed, it’s likely to stay that way, researchers from Harvard Medical School and other institutions reported recently in the Cancer Research journal.

Tumor grade is a description based on how abnormal the cancer cells look under a microscope, helping to predict how quickly the tumor is likely to grow and spread. For prostate cancer, the grading is called the Gleason score. It ranges from 2 to 10, and the higher the score, the more aggressive the cancer tends to be.

Doctors also use the PSA test (prostate-specific antigen), which measures the amount of a protein made by the prostate found in the blood. Levels may be higher in men with prostate cancer (though higher levels could also indicate an infection or a non-cancerous enlargement of the gland).

In the study reported in the Cancer Research journal, Harvard Medical School researchers followed more than 1,200 men who had their prostates removed after being diagnosed with prostate cancer between the years 1982 and 2004.

Over the course of the study, researchers found that the number of late-stage cancers that had spread beyond the prostate gland decreased — as expected given the increased use of the PSA test finding cancers earlier. Even more interesting is that among the men studied, the proportion of high-grade cancers remained fairly unchanged, as opposed to gradually becoming worse.  

This suggests that a tumor’s grade may be established early and it often doesn’t change. Or, as Kavoussi puts it, “Tigers don’t change their stripes.” That said, a small number of low-grade tumors may eventually become aggressive, illustrating the importance of being vigilant if you choose the active surveillance route.

“In general, if a man’s Gleason score is 6 or less and the PSA is less than 10, it’s likely he’ll be a candidate for active surveillance, but this has to be decided on a case-by-case basis and with your doctor,” Kavoussi says.


Take the next steps

Some physicians may suggest active surveillance, preferring not to expose patients to cancer treatment and its side effects if their particular form of prostate cancer isn’t life-threatening. If your doctor advises active surveillance:

  • Ask what exactly he means by the term. Doctors may use the term differently, with varying degrees of monitoring. “Active surveillance involves close monitoring such as PSA tests, digital rectal exams, ultrasounds and biopsies,” says Kavoussi. Together, you and your doctor should determine how closely you’ll be monitored, with which tests and how often.
  • Often, active surveillance is recommended when the cancer isn’t causing any symptoms, is expected to grow slowly, is small (or in early stage) and doesn’t extend beyond the prostate.
  • Consider getting a second opinion about whether active surveillance is the best idea for you at this time.

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