Is Active Surveillance Good for Prostate Cancer?

Active surveillance is an excellent option for many men diagnosed with low-risk prostate cancer, allowing them to avoid or delay treatment while maintaining close medical monitoring. Research shows that 10 years after diagnosis, 49% of men on active surveillance remained free of treatment or progression, with less than 1% dying from prostate cancer.

The answer depends on your cancer’s risk profile, age, overall health, and personal preferences. For men with low-risk disease, active surveillance prevents unnecessary treatment side effects while preserving the option for curative therapy if the cancer becomes more aggressive.

What Is Active Surveillance for Prostate Cancer?

Active surveillance is a structured monitoring approach for men diagnosed with localized prostate cancer that appears slow-growing and unlikely to cause harm. Unlike immediate treatment with surgery or radiation, active surveillance involves regular testing to detect any changes in cancer behavior before it becomes dangerous.

This strategy differs from “watchful waiting,” which is a less intensive approach typically reserved for older men with limited life expectancy. Active surveillance maintains curative intent through systematic monitoring with PSA blood tests, digital rectal exams, MRI scans, and repeat biopsies.

The goal is simple: avoid the side effects of prostate cancer treatment when the disease poses minimal risk, while ensuring early intervention if progression occurs. Between 50% and 68% of eligible patients safely avoid treatment for at least 10 years through this approach.

Who Qualifies for Active Surveillance?

Ideal candidates for active surveillance have very low-risk or low-risk prostate cancer confined to the prostate gland. The National Comprehensive Cancer Network defines very low-risk disease as clinical stage T1c, Gleason score 6 (Grade Group 1), PSA below 10 ng/mL, fewer than 3 positive biopsy cores, 50% or less cancer in each core, and PSA density under 0.15 ng/mL/g.

Men who meet these criteria and have a life expectancy exceeding 10 years represent optimal candidates. Some patients with favorable intermediate-risk disease (Gleason 3+4=7) may also qualify when cancer volume is low and specific biomarkers indicate less aggressive behavior.

Your suitability also depends on psychological factors. Successful active surveillance requires commitment to regular monitoring appointments and the ability to manage anxiety about living with untreated cancer. Men who experience significant distress from knowing cancer is present may prefer immediate treatment despite being medically eligible for surveillance.

How Does Active Surveillance Monitoring Work?

The monitoring protocol varies by institution but typically includes PSA testing every 3-6 months, digital rectal exams annually, and confirmatory prostate biopsies within 6-24 months of diagnosis. MRI scans are performed every 12-18 months initially, then every 3-5 years if results remain stable.

Johns Hopkins Medicine, which has followed over 2,000 men on active surveillance since 1995, reports a prostate cancer-specific mortality rate of only 0.1% over 15 years. Their protocol demonstrates that careful monitoring catches progression early enough for curative intervention.

If PSA levels rise significantly, your doctor may order an earlier MRI or biopsy. A PSA doubling time under 3 years often triggers additional imaging to check for disease progression. Changes detected during monitoring don’t necessarily mean treatment failure—they indicate the system is working as designed by identifying when intervention becomes necessary.

Commercial biomarker tests like Decipher, Oncotype DX Prostate, and Prolaris may help refine risk assessment. These genomic tests analyze biopsy tissue to predict cancer aggressiveness and can provide additional confidence in surveillance decisions for select patients.

Benefits of Choosing Active Surveillance

The primary advantage is avoiding treatment side effects while cancer remains indolent. Prostatectomy and radiation therapy can cause urinary incontinence, erectile dysfunction, and bowel problems that significantly impact quality of life. Active surveillance allows men to preserve sexual, urinary, and bowel function until treatment becomes medically necessary.

Studies demonstrate that patients treated after years of surveillance have outcomes comparable to those receiving immediate treatment. A 2024 study in JAMA found that fewer than 2% of men on active surveillance developed metastatic disease over 10 years, validating its safety for appropriate candidates.

Financial considerations also matter. Treatment for prostate cancer involves significant costs for surgery, radiation, or both, plus managing side effects. Active surveillance reduces upfront medical expenses while maintaining health insurance coverage for future treatment if needed.

The approach also provides time to make informed decisions. Many men feel rushed into treatment decisions immediately after diagnosis. Surveillance allows processing the diagnosis, researching options, and consulting multiple specialists before committing to irreversible treatments.

Potential Risks and Considerations

While generally safe for appropriate candidates, active surveillance carries some risks. Approximately 10% of patients develop anxiety during monitoring, struggling with uncertainty about cancer progression. This psychological burden can diminish quality of life for some men, making immediate treatment preferable despite medical eligibility for surveillance.

The possibility exists that cancer could become more aggressive during monitoring. However, this risk is minimal when protocols are followed consistently. About 50% of men on active surveillance transition to active treatment within 10 years, with most doing so within the first 5 years after detecting progression through regular testing.

Repeat biopsies pose infection risks, though newer imaging techniques may reduce biopsy frequency. MRI-guided biopsies offer improved accuracy over traditional methods, potentially catching progression earlier while requiring fewer procedures.

Some studies suggest disparities in active surveillance adoption. Research indicates that Hispanic men and those in rural areas have lower rates of surveillance enrollment, potentially due to access barriers or provider biases favoring treatment.

When Treatment Becomes Necessary

Conversion from surveillance to treatment typically occurs due to grade progression on repeat biopsy, increased tumor volume, concerning PSA kinetics, or patient preference. Evidence of Gleason score upgrading from 6 to 7 or higher represents the most common trigger for intervention.

Rising PSA density, clinical stage progression detected during digital rectal exams, or suspicious findings on MRI scans may also prompt treatment discussions. Some patients simply decide they no longer wish to live with active cancer, regardless of medical stability.

Treatment options remain the same as at initial diagnosis: radical prostatectomy, radiation therapy, or newer approaches like minimally invasive surgery using the da Vinci robotic system. St Pete Urology’s specialists have extensive experience with advanced surgical techniques that minimize side effects while maximizing cancer control.

The window for cure does not disappear during surveillance. Men treated after monitoring have cure rates similar to those receiving immediate treatment, provided progression is caught through scheduled testing.

Long-Term Outcomes and Success Rates

Long-term data supports active surveillance safety for low-risk disease. The ProtecT trial, which followed patients for 15 years, found no difference in prostate cancer-specific survival between active monitoring, surgery, and radiation groups. While metastasis rates were slightly higher with monitoring (9.4% versus 4.7% for surgery), deaths from prostate cancer remained extremely rare in all groups.

The University of Toronto cohort study tracked men for over 20 years, with some never requiring treatment. These patients avoided decades of living with treatment side effects while maintaining excellent cancer outcomes through vigilant monitoring.

Approximately 49% of men remain on surveillance without progression at 10 years, according to recent research. This means nearly half avoid treatment entirely during the initial decade after diagnosis, preserving quality of life while cancer remains stable.

For those who do transition to treatment, outcomes are excellent. Studies show no difference in metastasis or survival rates between men treated immediately versus those treated after surveillance detected progression.

Making the Right Decision for You

Choosing between active surveillance and immediate treatment requires weighing multiple factors. Consider your cancer characteristics, overall health, life expectancy, risk tolerance, and support system. Consulting with experienced urologists helps clarify which approach aligns with your medical situation and personal values.

St Pete Urology’s board-certified urologists have helped thousands of Tampa Bay men navigate prostate cancer decisions. Dr. Nicholas Laryngakis, Dr. Reid Graves, and Dr. Adam Oppenheim specialize in comprehensive prostate cancer care, including active surveillance programs tailored to each patient’s needs.

Active surveillance represents a proven, evidence-based approach for men with low-risk prostate cancer. With disciplined monitoring and access to expert care, it allows preserving quality of life while maintaining excellent long-term outcomes. Contact St Pete Urology at (727) 478-1172 to discuss whether active surveillance is right for your situation.

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References

• American Cancer Society. (2024). Active surveillance for prostate cancer. https://www.cancer.org/cancer/types/prostate-cancer/treating/watchful-waiting.html
• Fred Hutchinson Cancer Center. (2024, May 30). Active surveillance shown to be an effective management strategy for prostate cancer patients. https://www.fredhutch.org/en/news/releases/2024/05/active-surveillance-shown-to-be-an-effective-management-strategy.html
• Johns Hopkins Medicine. (2025). Active surveillance for prostate cancer. https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/active-surveillance-for-prostate-cancer
• National Cancer Institute. (2022). Active surveillance for prostate cancer increasing. https://www.cancer.gov/news-events/cancer-currents-blog/2022/prostate-cancer-active-surveillance-increasing