Active surveillance, or AS, (sometimes called active monitoring) is a management option suitable for some men with prostate cancer. AS means that there won’t be any immediate treatment, as treatment is deferred or postponed until the urologist or CNS (clinical nurse specialist) feels it necessary to treat the prostate cancer because of recent test results.
AS might be suggested:
- When cancer is found in the early stages, is still inside the prostate and is thought to be low-risk of progression or prognostic grade group 1. It may be an option for a small number of men with intermediate-risk prostate cancer or prognostic grade group 2; (for more details on prognostic grade group and risk please see pages 28 to 32 of the booklet ‘Early prostate cancer explained‘)
- For men aged under 75 with a life expectancy of 10 years or more;
- For men over 70, as the cancer is unlikely to grow fast enough to cause problems during their lifetime;
- For younger men who have concerns that the side-effects of treatment will have a greater effect on their life than the cancer. They may prefer to put off the risk of side-effects for as long as possible (called deferred radical treatment).
There may be additional local guidelines you may have to meet to be considered for AS. Ask your consultant or CNS for more information.
How is AS monitored?
As protocols or guidelines may vary throughout Scotland, a typical approach might be:
|Timing in years||Tests|
|Enrolment in AS||After initial tests have confirmed prostate cancer|
|Year 1||Measure PSA every 3 months*
DRE (digital rectal examination) every 12 months
At the end of the first year, repeat MRI and/or prostate biopsy
(recent changes in NICE guidelines suggest that if all test results are thought to be satisfactory at this point, then routine repeat biopsy is unnecessary)
|Years 2 -4||Measure PSA every 3 months*
DRE every 12 months
|Year 5 +||Measure PSA every 6 months
DRE every 12 months
*Your PSA test will usually be done at your GP Practice before your hospital appointment so the urologist has the up-to-date result available.
Further routine biopsies are not now recommended, are now usually done if the urologist or CNS notes changes in your PSA levels, DRE or if they think a biopsy is necessary.
In certain areas, you may have regular follow-up MRI scans.
So, as can be seen, AS does involve close monitoring of the cancer and will mean regular appointments with the GP practice and follow-up visits and tests at the hospital to ensure that the cancer does not progress whilst under surveillance.
When will another form of treatment need to be considered?
Having all the checks done regularly should show if or when the cancer starts to progress by becoming more aggressive.
Treatment can be started if the man and his family change their mind about AS or if the cancer shows signs of growing faster or looks as if it might spread outside the prostate.
These signs include:
• The PSA level rising very quickly;
• An increase in the Gleason score or prognostic grade group;
• Changes to the prostate during a DRE. This could be the prostate changing in size, shape or the doctor feeling a lump or hardened area;
• A biopsy shows significant increase in volume of the cancer.
If this is the case, then further treatment options will be discussed with the man and his family by the urologist, oncologist or CNS. These might include radical prostatectomy, external beam radiotherapy or brachytherapy.
For further information about active surveillance see the booklets:
Early Prostate Cancer explained (pages 44 -51)
Active Surveillance as a management for early prostate cancer