Not every prostate cancer needs treatment straight away. Some grow so slowly they may never cause problems, while treatment can affect urine control and sexual function. This guide explains active surveillance, how it differs from watchful waiting, who it suits according to UK and European guidelines, what monitoring involves, when treatment is offered, and when to contact your doctor.
Medically reviewed by Prof. Dr. Samir Ahmed Al-Samarrai, consultant urologist. Last reviewed: · Last updated:
What active surveillance is, and how it differs from watchful waiting
Active surveillance is a planned way of monitoring a prostate cancer that is small, slow-growing and confined to the prostate. Instead of treating straight away, the care team checks the cancer with regular tests. According to Cancer Research UK, treatment starts if the cancer changes, and that treatment aims to cure it, usually with surgery or radiotherapy.
Watchful waiting is different: Prostate Cancer UK explains that it usually aims to control symptoms rather than cure, with fewer tests, often at the family doctor. The European Association of Urology (EAU) describes active surveillance as having curative intent and watchful waiting as having palliative intent.
Who active surveillance may suit
Guidelines use risk groups based on the Gleason score (grade group), the PSA level and the stage of the cancer:
- NICE (UK): uses the Cambridge Prognostic Groups (CPG). CPG 1 means Gleason score 6 (grade group 1) and PSA below 10, with stage T1-T2. NICE recommends offering active surveillance for CPG 1, offering a choice between active surveillance, surgery or radiotherapy for CPG 2, and considering it for CPG 3 only for men who decline immediate radical treatment. NICE says not to offer it for CPG 4 and 5.
- EAU (Europe): active surveillance is for low-risk and selected intermediate-risk disease. According to the EAU, the most widely used criteria are ISUP grade group 1, PSA below 10 and a low PSA density, and men with certain high-risk features under the microscope (cribriform or intraductal patterns) should be excluded.
Doctors also check fitness for curative treatment if needed later.
How the cancer is diagnosed and assessed first
Before surveillance is considered, the diagnosis and risk group must be clear. This usually involves a PSA blood test, a prostate MRI scan and a biopsy that shows the Gleason score. NICE recommends offering an MRI to men on surveillance who have not had one. The EAU notes that if the first biopsy was done without MRI, a confirmatory biopsy is needed within the first year.
The monitoring schedule
Schedules vary. As an example, the NICE protocol suggests:
- Year 1: PSA every 3 to 4 months, a digital rectal examination (DRE) at 12 months, and an MRI at 12 to 18 months.
- Year 2 onwards: PSA every 6 months and a DRE every 12 months.
- At any time: a repeat MRI and/or biopsy if there is concern about PSA or clinical changes.
The EAU suggests PSA at least every six months, DRE at least yearly, and a repeat biopsy (with or without MRI) every 2 to 3 years. Prostate Cancer UK says a biopsy may only be needed if other tests suggest the cancer is growing.
When treatment is offered
According to NICE, radical treatment is offered when there is evidence that the disease is progressing. The EAU advises that the decision to change to treatment should be based on biopsy findings, such as a higher grade, rather than on a PSA rise or MRI change alone; these should lead to further tests. Prostate Cancer UK adds that a man can choose treatment at any time, even without signs of change. Options such as radical prostatectomy or radiotherapy are decided with the specialist team.
Comparing the three approaches
| Feature | Active surveillance | Watchful waiting | Radical treatment |
|---|---|---|---|
| Aim | Cure if the cancer changes | Control symptoms if they appear | Cure now |
| Who it suits | Low-risk and some intermediate-risk localised cancer | Men with other health problems or shorter life expectancy, any risk group | Localised cancer where treatment is suitable and wanted |
| Tests | Regular PSA, MRI, DRE, biopsy if needed | Fewer tests, PSA about once a year | Follow-up tests after treatment |
| Treatment side effects | Avoided unless treatment is needed | Avoided unless symptoms need treatment | Possible effects on urine control and erections |
Summarised from the EAU, Prostate Cancer UK and the NHS.
Advantages, disadvantages and living with it
According to Prostate Cancer UK, the main advantage is avoiding the side effects of treatment, such as the urinary and erection problems the NHS lists after prostate removal, while keeping curative treatment available. Disadvantages include frequent appointments, possible repeat biopsies, and worry about not being treated. Cancer Research UK also mentions the stress of waiting for results.
Long-term research is reassuring. According to ESMO’s report of the ProtecT trial, after 15 years deaths from prostate cancer were 3.1% in the monitoring group, 2.2% after surgery and 2.9% after radiotherapy, with no significant difference. The cancer spread more often in the monitoring group (9.4% compared with about 5%), and that trial’s monitoring was less intensive than modern surveillance.
Prostate Cancer UK advises healthy eating, regular exercise and stopping smoking, and avoiding sexual activity and vigorous exercise for 48 hours before a PSA test.
When to contact your doctor
Keep all appointments and tell your doctor promptly about:
- changes in urination, such as needing to go more often, especially at night, or a weak flow
- blood in the urine
- new pain in the back, hips or bones
- unexplained weight loss, unusual tiredness or new leg swelling
Urinary changes are often due to an enlarged prostate, Prostate Cancer UK notes, but should still be checked. Seek urgent care if you cannot pass urine at all.
Frequently asked questions
Is active surveillance the same as doing nothing?
No. Active surveillance is a structured programme of regular PSA tests, examinations and MRI scans, with biopsies when needed. According to Cancer Research UK, its purpose is to start treatment that aims to cure the cancer if tests show it is changing, while avoiding unnecessary treatment for cancers that stay stable.
What is the difference between active surveillance and watchful waiting?
Active surveillance aims to cure the cancer if it progresses and uses hospital tests. Watchful waiting, as Prostate Cancer UK describes it, usually aims to control symptoms rather than cure, involves fewer tests, and suits men with other health problems or whose cancer is unlikely to affect their life expectancy.
Will I need repeat biopsies?
Possibly. Practice differs. The EAU suggests repeat biopsies at intervals, while Prostate Cancer UK says some hospitals only do a biopsy when PSA, examination or MRI results suggest the cancer is growing. Your specialist will explain your plan.
Can I change my mind and have treatment?
Yes. Prostate Cancer UK says men can choose treatment at any time, even without signs that the cancer has changed. NICE recommends that any move to radical treatment is a shared decision between you and your care team, after discussing the options and their possible side effects.
Does a rise in PSA mean I need treatment?
Not by itself. According to the EAU, a PSA change alone should lead to further tests, such as an MRI and a biopsy, rather than an immediate change to treatment. The decision is usually based on biopsy findings.
Is there anything I can do while on surveillance?
Prostate Cancer UK recommends a healthy diet, regular exercise and stopping smoking. It advises avoiding sexual activity and vigorous exercise for 48 hours before a PSA test so the result is reliable. Tell your care team if worry about the cancer is affecting you.
Sources
- Prostate cancer: diagnosis and management (NICE guideline NG131)
- Treatment – EAU Guidelines on Prostate Cancer
- Active surveillance and watchful waiting for prostate cancer – Cancer Research UK
- Active surveillance – Prostate Cancer UK
- Watchful waiting – Prostate Cancer UK
- Treatment for prostate cancer – NHS
- Mortality From PSA-Detected Localised Prostate Cancer Remains Very Low Regardless of Whether Patients Received Active Monitoring, Prostatectomy or Radiotherapy – ESMO
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