Watchful waiting or active surveillance for prostate cancer

Because prostate cancer often grows very slowly, some men (especially those who are older or have other serious health problems) might never need treatment for their prostate cancer. Instead, their doctors may recommend approaches known as watchful waiting oractive surveillance. (Other terms sometimes used include observation or expectant management.)

Some doctors use the terms active surveillance and watchful waiting to mean the same thing. For other doctors these terms mean something slightly different:

• Active surveillance is often used to mean monitoring the cancer closely. Usually this approach includes a doctor visit with a prostate-specific antigen (PSA) blood test and digital rectal exam (DRE) about every 6 months. Prostate biopsies may be done every year as well. If your test results change, your doctor would then talk to you about treatment options.
• Watchful waiting (observation) is sometimes used to describe a less intensive type of follow-up that may mean fewer tests and relying more on changes in a man’s symptoms to decide if treatment is needed.

Not all doctors agree with these definitions or use them exactly this way. In fact, some doctors prefer to no longer use the term watchful waiting. They feel it implies that nothing is being done, when in fact a man is still being closely monitored.

No matter which term your doctor uses, it’s very important for you to understand exactly what he or she means when they refer to it.

When might these approaches be an option?

One of these approaches might be recommended if your cancer:

· Isn’t causing any symptoms

· Is expected to grow slowly (based on Gleason score)

· Is small

· Is just in the prostate

These approaches are not likely to be a good option if you have a fast-growing cancer (for example, a high Gleason score) or if the cancer is likely to have spread outside the prostate (based on PSA levels). Men who are young and healthy are less likely to be offered active surveillance, out of concern that the cancer might become a problem over the next 20 or 30 years.

Watchful waiting and active surveillance are reasonable options 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 to try to remove or destroy the cancer.

In active surveillance, only men whose cancer is growing (and therefore have a more serious form of cancer) are treated. This lets men with less serious cancer avoid the side effects of a treatment that might not have helped them live longer. A possible downside of this approach is that it might give the cancer a chance to grow and spread. This might limit your treatment options, and could possibly affect the chances of the cancer being treated successfully.

Not all experts agree how often testing should be done during active surveillance. There is also debate about when is the best time to start treatment if things change.

Comparing watchful waiting or active surveillance with active treatment

A few large studies have compared watchful waiting (where men were treated only if they developed symptoms from their cancer) and surgery for early stage prostate cancer, but the evidence from these studies has been mixed. Some have found that men who have surgery might live longer, while others have not found a difference in survival.

So far, no large studies have compared active surveillance to treatments such as surgery or radiation therapy. Some early studies of men who are good candidates for active surveillance have shown that only about a third of the men need to go on to treatment with radiation or surgery.