Active Surveillance: Monitoring Low-Risk Prostate Cancer

By Nicholas Zuk

Prostate cancer, with 13% of Americans expected to develop it in their lifetime, is one of the most commonly diagnosed forms of cancer in men (CDC, 2024). Fortunately, most cases of prostate cancer are non-emergent and slow spreading, often taking years to become large enough to detect or to spread outside of the prostate (Rohini Radhakrishnan, 2021). For patients with low-risk prostate cancer, active surveillance has emerged as a safe and effective alternative to traditional treatment methods. By closely monitoring the patient’s condition, the patient can forego immediate surgery or other invasive treatment methods that can carry significant side effects. Through regular checkups and utilizing monitoring methods such as advanced imaging, patients can avoid overtreatment with the reassurance that any indicators of cancer progression will be caught early. While active surveillance may seem like a straightforward method of treatment, understanding what it is, how it works, and how to play an active role in surveilling a prostate cancer diagnosis can allow a patient to approach their diagnosis more confidently.

            Active surveillance, a method designed to manage low-risk prostate cancer, offers a balanced approach. It involves frequent screenings to avoid the need for expensive, debilitating, and unnecessary treatment options. Unlike traditional cancer treatments such as surgery, radiation, or chemotherapy, which can be highly invasive, active surveillance is often a more suitable choice for prostate cancer due to its slow growth and spread. 

While traditional treatment methods can provide more direct, tangible results than active surveillance, traditional methods can also cause various adverse side effects that can impact a patient’s life. Common side effects of radiation and surgery, such as incontinence and erectile dysfunction, can cause months or years of discomfort that could have been avoided if active surveillance was the method of treatment. Additionally, research has shown that the long-term health outcomes for low-risk patients using active surveillance are comparable to those of patients who seek immediate treatment (Carlsson et al., 2020). For many, avoiding invasive procedures and the challenges that come with them makes active surveillance the preferred option. 

            To understand what active surveillance is, it is first essential to define what qualifies as low-risk prostate cancer. First, for prostate cancer to be considered low-risk, a patient’s cancer must have a Gleason score of 6 or below (Fox Chase Medical Center, 2020). The Gleason system is used to grade prostate cancer tumors to assess cell abnormalities, with a score of 6 indicating low-grade cancer and 10 indicating high-grade cancer. Second, a patient must have prostate-specific antigen (PSA) levels below 10 nanograms per milliliter (ng/mL) of blood (Fox Chase Medical Center, 2020). Finally, there must be no indication that cancer has grown or metastasized. If all criteria are met, immediate treatment is unnecessary in many cases, making active surveillance a good treatment option.

            Active surveillance as a treatment is a structured plan to monitor low-risk prostate cancer through regular medical tests and exams. Typically, plans include PSA blood tests, digital rectal exams (DREs), magnetic resonance imaging, and biopsies. PSA blood tests are performed every 3-6 months and are used to track changes in PSA levels that are indicative of prostate cancer activity (David, 2024). Digital rectal exams are generally conducted by medical professionals at least once a year to assess the size and shape of the prostate physically (Johns Hopkins Medicine, 2024). MRIs are used throughout the active surveillance process for initial screenings, biopsy guidance, and follow-up monitoring throughout treatment (NYU Lagoon Health, 2021). Finally, biopsies are performed every 1-3 years to examine prostate tissue for signs of cancer progression or metastasis (Johns Hopkins Medicine, 2024). The specific frequency and monitoring a patient receives is tailored by a patient’s healthcare specialist based on factors like age, PSA velocity, and health history. By adhering to their surveillance plan, patients can feel confident in managing their low-risk prostate cancer. 

            For active surveillance to be effective, patients must actively participate and remain engaged in the monitoring process. To do so, patients must be educated on their diagnosis, have a good relationship with their healthcare providers, and make healthy lifestyle choices to optimize health outcomes. First, staying up-to-date on the details of how prostate cancer is diagnosed and becoming familiar with terms such as PSA levels, the Gleason score, and the protocols for monitoring low-risk prostate cancer, are essential for understanding how important it is for a patient to show up to scheduled appointments and maintain frequent contact with their healthcare providers. Websites for the American Cancer Society, the Prostate Cancer Foundation, and the National Comprehensive Cancer Network are all resources that provide clear, evidence-based guides on topics about prostate cancer and active surveillance. Further, CancerAcademy has mini-courses that provide information on various prostate cancer topics. Digital apps and trackers are other tools that aid in keeping track of test results, appointments, and symptoms. Apps such as “My Prostate Cancer Coach” and “CareZone” provide patients with information on treatment options and allow them to log appointment notes, keep track of when checkups are, and log health records in one place.

Second, research also suggests that adopting a healthy lifestyle can improve overall well-being and functional outcomes for all patients with prostate cancer (Zuniga, Chan, Ryan, & Kenfield, 2020). Integrating low-saturated fat, plant-based, whole-food diets, maintaining an exercise routine (walking, cycling, yoga, swimming, etc.), and practicing stress reduction techniques (meditation, etc.) appear to be the most effective lifestyle choices for prostate cancer patients (Zuniga, Chan, Ryan, & Kenfield, 2020). By adopting these practices, a patient can improve overall health and support the effectiveness of active surveillance by optimizing their physical resilience. 

Finally, patients need to keep their oncologists updated on their condition. While active surveillance is focused on low-risk patients, remaining vigilant for signs of cancer progression such as difficulty or pain while urinating, blood in urine, difficulty achieving or maintaining an erection, or pain and general weakness in the lower torso should be reported immediately so that interventions can be made as early as possibly. Equally important is having a supportive and experienced medical team that is familiar with active surveillance and will offer guidance and reassurance throughout the process. By being proactive in monitoring their condition, patients can manage life with low-risk prostate cancer while maintaining their previous quality of life. 

            While active surveillance is an effective method of approaching low-risk prostate cancer, when progression does occur, steps must be taken to ensure patients remain healthy. This, however, does not mean urgent and aggressive treatment is absolutely necessary. Because prostate cancer is usually identified through changes in indicators such as PSA levels, biopsy results, and MRI scans, so too is the progression of the cancer. Steady increases in PSA levels may indicate the spread of active cancer cells in the prostate. Further, biopsy results that lead to a Gleason score between 7-10 can indicate the cancer has shifted from low-risk to medium or high-risk. Finally, any structural changes in the prostate found by MRIs can represent cancer progression. 

            If progression is detected and is severe enough, it may be deemed necessary for patients to transition to more active treatment methods that may require surgery, radiation therapy, or hormone therapy. A radical prostatectomy is a standard and effective surgical procedure that removes the entire prostate gland to address advanced cancer (Johns Hopkins Medicine, 2024). Though effective, this procedure can cause unwanted side effects such as incontinence or erectile dysfunction. Intensity-modulated radiation therapy (IMRT) is another treatment used both independently as well as following surgery that destroys cancer cells using energy targeted at the prostate and surrounding tissue. Short-term side effects include diarrhea, nausea, hair loss, fatigue, and hemorrhoids. Long-term effects include proctitis (inflammation of the rectum), incontinence, and impotence. Hormone therapy is also used to lower testosterone levels to slow cancer growth (Canadian Cancer Society, 2021). In some situations, a combination of these treatments is used if the cancer has metastasized. Though the possibility of prostate cancer progressing is daunting for a patient, active surveillance is specifically designed to address this uncertainty and make sure that interventions are made as early as possible and only if necessary. 

            Active surveillance has emerged as a transformative approach for managing low-risk prostate cancer that offers patients the ability to avoid the invasive treatments often associated with traditional cancer care. By staying informed about protocols and prioritizing regular monitoring and proactive communication with healthcare providers, patients can confidently navigate their diagnosis and minimize overtreatment. Utilizing educational resources, digital health trackers, and personalized care plans further support this process and ensure patients are prepared to manage their condition. 

While there is always the possibility of cancer progressing, closely tracking PSA levels and imaging results allows healthcare providers to identify changes early and swiftly intervene. With this approach, patients receive the care they need without undergoing unnecessary treatments. By combining regular monitoring with informed decision-making and ongoing support from a trusted medical team, patients with low-risk prostate cancer can take control of their health and approach their journey with reassurance, knowing that they have the best balance of effective care while also preserving their overall well-being.

References

Canadian Cancer Society / Société canadienne du cancer. (2021). Hormone therapy for prostate cancer. Retrieved from https://cancer.ca/en/cancer-information/cancer-types/prostate/treatment/hormone-therapy#:~:text=Hormone%20therapy%20is%20often%20used,as%20surgery%20or%20radiation%20therapy 

Carlsson, S., Benfante, N., Alvim, R., Sjoberg, D. D., Vickers, A., Reuter, V. E., … Touijer, K. (2020). Long-term outcomes of active surveillance for prostate cancer: The Memorial Sloan Kettering Cancer Center Experience. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC7480884/#:~:text=The%20median%20age%20at%20diagnosis,1–4 

CDC. (2024). Prostate cancer risk factors. Retrieved from https://www.cdc.gov/prostate-cancer/risk-factors/index.html#:~:text=Out%20of%20every%20100%20American,common%20risk%20factor%20is%20age. 

David, M. K. (2024). Prostate-specific antigen. Retrieved from https://www.ncbi.nlm.nih.gov/books/NBK557495/#:~:text=PSA%20monitoring%20for%20patients%20on%20active%20surveillance,a%20total%20PSA%20greater%20than%2010%20ng/mL. 

Fox Chase Medical Center. (2020). The Gleason Score Explained. Retrieved from https://www.foxchase.org/clinical-care/conditions/prostate-cancer/prostate-cancer-diagnosis/staging 

Johns Hopkins Medicine. (2024a). Radical prostatectomy. Retrieved from https://www.hopkinsmedicine.org/health/treatment-tests-and-therapies/radical-prostatectomy 

Johns Hopkins Medicine. (2024b). Active surveillance for prostate cancer. Retrieved from https://www.hopkinsmedicine.org/health/conditions-and-diseases/prostate-cancer/active-surveillance-for-prostate-cancer#:~:text=Active%20Surveillance%20Testing%20Schedule&text=PSA%20testing%20every%20three%20to,to%2012%20months%20of%20diagnosis) 

NYU Lagoon Health. (2021). Active surveillance for prostate cancer is more cost-effective with MRI. Retrieved from https://nyulangone.org/news/active-surveillance-prostate-cancer-more-cost-effective-mri#:~:text=Photo:%20skynesher/Getty,harbors%20the%20clinically%20significant%20cancer. 

Prostate Cancer UK. (2022). Digital Rectal Examination (DRE). Retrieved from https://prostatecanceruk.org/prostate-information-and-support/prostate-tests/digital-rectal-examination-dre 

Rohini Radhakrishnan, E. (2021). How quickly does prostate cancer spread? Retrieved from https://www.medicinenet.com/how_quickly_does_prostate_cancer_spread/article.htm 

Zuniga, K. B., Chan, J. M., Ryan, C. J., & Kenfield, S. A. (2020). Diet and lifestyle considerations for patients with prostate cancer. Retrieved from https://pmc.ncbi.nlm.nih.gov/articles/PMC7293879/#:~:text=There%20is%20a%20well%2Destablished,red%20meat%2C%20and%20saturated%20fat.