Not Every Prostate Cancer Needs Surgery: Understanding Active Surveillance

Hearing a prostate cancer diagnosis can understandably raise questions about whether treatment is needed immediately. For some men with low-risk disease, a urologist may recommend monitoring the cancer closely rather than starting surgery or radiation straight away. This approach is called active surveillance. It is an established management option for appropriately selected patients, but it requires regular clinical review and testing. This blog explains how active surveillance works, who may be eligible, and when treatment may become necessary.

Why Some Prostate Cancers Don't Need Immediate Treatment

Prostate cancer is not a single disease. Some tumours are aggressive and need prompt treatment. Many others, especially those found through PSA testing, grow so slowly that they may never cause symptoms or shorten a man's life. Autopsy studies show that a large share of older men who died of other causes had small prostate cancers they never knew about.

Treating every one of these slow-growing cancers with surgery or radiation exposes men to real side effects, including urinary leakage, erectile dysfunction and bowel problems, for a cancer that may never have harmed them. This is called overtreatment, and active surveillance was developed to prevent it.

What Is Active Surveillance?

Active surveillance is a structured monitoring programme for selected men with low-risk prostate cancer. Instead of beginning treatment immediately, the urologist monitors the cancer with scheduled assessments. If biopsy results or other findings suggest the cancer has become more aggressive, surgery or radiation may be considered, depending on the patient’s health, disease characteristics and preferences.

The key word is active. This is not ignoring the cancer. It is a planned approach with regular monitoring and defined reasons to reassess treatment.

Active Surveillance vs Watchful Waiting

The two terms are often confused, but they are different:

• Active surveillance: aimed at men who are fit enough for curative treatment; involves regular PSA tests, MRI and repeat biopsies; the goal is to cure the cancer if it progresses
• Watchful waiting: usually for older men or those with serious health problems; involves fewer tests; the goal is to manage symptoms if they appear, rather than to cure

Who Is a Good Candidate?

Active surveillance is commonly considered for men with the following features, although eligibility requires individual assessment:

• Grade Group 1 cancer (Gleason score 3 + 3 = 6) on biopsy
• A PSA level typically below 10 ng/mL
• Cancer confined to the prostate (early clinical stage)
• A small amount of cancer found in only a few biopsy samples

Some men with carefully selected favourable intermediate-risk cancer (Grade Group 2 with a small amount of pattern 4) may also be considered after detailed discussion. MRI findings, PSA density, family history and, in selected situations, additional tests help refine the decision. Higher-grade disease and certain inherited risk factors, including BRCA2 alterations, can affect suitability and require specialist evaluation.

What Does Active Surveillance Involve?

Each hospital follows its own protocol, but a typical schedule includes:

• PSA blood tests: every 3 to 6 months
• Digital rectal examination: usually once a year
• Multiparametric MRI of the prostate: at the start and then periodically, or sooner if PSA rises
• Repeat (confirmatory) biopsy: often within the first year, then every few years or when MRI or PSA suggests a change

These assessments look for signs that the cancer is changing. A confirmatory biopsy may be recommended to check whether a more aggressive area was missed at diagnosis; the timing and frequency of testing vary by individual risk and local protocol.

When Is Treatment Recommended?

A urologist will usually recommend moving to active treatment if:

• A repeat biopsy shows a higher Gleason score or Grade Group
• A larger amount of cancer is found on biopsy
• The MRI shows the tumour growing or a new suspicious area
• A PSA pattern raises concern and prompts further assessment; PSA change alone does not necessarily mean immediate treatment
• The patient prefers to switch to treatment for personal reasons

Moving to treatment is not a failure of surveillance. It reflects reassessment of the available findings and the balance between the potential benefits and risks of treatment.

Is Active Surveillance Safe?

Research supports active surveillance as an option for appropriately selected men with low-risk prostate cancer. In the UK ProtecT trial, prostate cancer deaths over approximately 15 years were uncommon across active monitoring, surgery and radiotherapy groups, although metastases and disease progression occurred more often with monitoring. The trial’s active monitoring protocol was not identical to contemporary active surveillance, which may incorporate MRI and repeat biopsies. These findings should not be interpreted as evidence that monitoring carries no risk.

The Benefits and the Challenges

Benefits:

• Avoiding or delaying the side effects of surgery and radiation, especially urinary leakage and erectile dysfunction
• Keeping normal quality of life and daily routine
• Keeping the option of curative treatment open if it becomes necessary

Challenges:

• Regular tests and repeat biopsies, which carry small risks such as infection or bleeding
• Anxiety about "living with cancer" for some men and their families
• A small risk that the cancer progresses between check-ups

Discussions with the urologist, and support from a partner or family member if desired, may help patients manage uncertainty and make informed choices.

Staying Healthy on Surveillance

Active surveillance is a good time to invest in overall health. Regular exercise, a healthy weight, a diet rich in vegetables and whole grains, stopping smoking and moderating alcohol all support heart health and general wellbeing. These steps may also help men cope better with treatment if it is ever needed.

Conclusion

A prostate cancer diagnosis does not automatically mean surgery. For selected men with low-risk disease, active surveillance may allow immediate treatment to be deferred while the cancer is assessed regularly. It also carries risks, including the possibility of progression. Decisions should take account of biopsy findings, PSA, MRI, age, overall health and personal preferences, in discussion with the treating urologist.

Contact Us

The Gujarat Uro Oncology Associates team offers expert consultation, diagnosis, second opinions, and treatment planning for urological cancers. To learn more or book an appointment, contact 91 75730 04253 or email bakshihemang@yahoo.co.in.