By Rodney Herbert

Prostate cancer is often slow-growing, and many men do not need immediate treatment. Instead, doctors may suggest monitoring the cancer over time. Two main monitoring strategies are Active Surveillance and Watchful Waiting. While they sound similar, they have important differences in approach, follow-up, and goals. Below, we compare and contrast these strategies in plain language, so you can understand which might be right for you or your loved one.

What Are Active Surveillance and Watchful Waiting?

Active Surveillance and Watchful Waiting are both ways to avoid or delay treatment for prostate cancer, but they are not the same thing:

Active Surveillance (AS): This is a planned monitoring approach. The cancer is watched closely with regular tests. The goal is to catch any signs of growth or change early and treat promptly with curative intent if needed www1.racgp.org.au

In other words, the doctor and patient actively keep an eye on the prostate cancer and will step in to cure it if it starts to act more aggressive.
Watchful Waiting (WW): This is a more passive observation approach. It usually means no routine cancer tests on a fixed schedule auanet.org

Instead, the doctor will wait for symptoms to appear and then treat cancer only to relieve symptoms(palliative treatment), not to cure

The goal of watchful waiting is to maintain quality of life without exposing the patient to treatment side effects since the cancer is unlikely to cause death or serious harm in that patient’s expected lifespan.

In simpler terms, Active Surveillance is like regular check-ups to make sure the cancer isn’t growing and to cure the cancer if it changes. Watchful Waiting is doing very minimal checks and only treating problems if they come up, not trying to cure the cancer. Both approaches aim to avoid unnecessary treatment of a slow prostate cancer, but they differ in how much monitoring is done and why.

Who Is a Good Candidate for Each Approach?

Whether a man is placed on active surveillance or watchful waiting depends on several factors, including the characteristics of his cancer, his age and overall health, and his personal preferences. Here are some general criteria and situations for each strategy:

Active Surveillance is typically recommended for:
- Low-risk prostate cancer: This means the cancer is small, contained in the prostate, and appears slow-growing. For example, it might be a low PSA (prostate-specific antigen) level and a low-grade tumor. Doctors often describe this as “very low” or “low risk” disease. Studies show that treating these low-risk cancers right away does not improve survival but does add side effects. So, monitoring is a safe choice.
  - Men with a long life expectancy: Generally, if a man is expected to live 10 or more years (for instance, a younger or very healthy older man), active surveillance is considered. Since these men may live long enough for cancer to grow, it makes sense to watch closely and keep the option to cure open pmc.ncbi.nlm.nih.gov
    
    Men who are willing and able to follow the surveillance schedule: Active surveillance requires regular doctor visits, blood tests, and sometimes biopsies. The best candidates are men who can stick with this plan and are comfortable with the idea of “living with cancer” under observation. They understand that if the cancer shows signs of danger, treatment will be started at that time.
Watchful Waiting is typically considered for:
- Older men or those with serious other health problems: If a man’s life expectancy is shorter (generally less than 10 years, and especially if less than 5 years), due to age or other illnesses, watchful waiting may be recommended. In this case, the prostate cancer is unlikely to cause issues before something else does, so aggressive monitoring or treatment isn’t needed.
- Any risk level when cure is not the goal: Even if the cancer is intermediate or high-risk, if the patient cannot tolerate treatment or won’t benefit long-term because of limited lifespan, doctors may choose watchful waiting. The focus would then be on managing symptoms if they occur, such as bone pain or urinary blockage, using treatments like hormone therapy to provide relief. In essence, WW can apply to patients with any stage of cancer if their situation means treatment would do more harm than good.
- Men who strongly wish to avoid treatment side effects above all else: Some patients, after discussion, prefer not to undergo frequent tests or any treatments unless absolutely necessary. They accept the possibility that the cancer might eventually cause symptoms, and they choose comfort and quality of life now over aggressive follow-up. For these men, especially if the cancer is currently not causing symptoms, watchful waiting might be an option.

It’s important to note that the distinction often comes down to life expectancy and cancer aggressiveness. For a younger, healthier man with mild (low-risk) cancer, active surveillance is usually the best approach to delay or avoid treatment without compromising survival. For an older man (for example, in his 80s) or someone in poor health, especially if the cancer is low-risk, watchful waiting lets him avoid the hassle of constant tests and the side effects of treatments he likely doesn’t need.

What Do the Guidelines Say? (2023–2025 Recommendations)

Major cancer organizations around the world endorse the use of active surveillance and watchful waiting in the appropriate settings. Here are some key points from recent guidelines (as of 2023–2025) by expert groups like the NCCN (National Comprehensive Cancer Network) in the US, the AUA (American Urological Association), and the EAU (European Association of Urology):

Active Surveillance for Low-Risk Cancer: It is strongly recommended for most men with low-risk prostate cancer who have a significant life expectancy. For example, NCCN guidelines prefer active surveillance as the first option for low-risk patients who are likely to live at least 10 yearspmc.ncbi.nlm.nih.gov

The EAU guidelines likewise state that active surveillance is backed by strong evidence for low-risk disease in men expected to live 10+ years

pmc.ncbi.nlm.nih.gov

In fact, active surveillance is now considered the standard of care for low-risk prostate cancer in many countries.
Active Surveillance for Intermediate-Risk Cancer: Some men with favorable intermediate-risk prostate cancer (a step above low-risk, meaning a little higher PSA or a Grade Group 2 tumor) may also be offered active surveillance, with caution. The AUA and other groups say that “favorable” intermediate cases (small amounts of Gleason 3+4 cancer, for instance) can consider surveillance, but doctors must counsel that the risk of the cancer growing or spreading is higher than in truly low-risk cases

For these patients, it’s a careful decision based on individual factors – surveillance is an option if the patient understands the trade-offs. Guidelines emphasize shared decision-making in this scenario.
Watchful Waiting in Guidelines: All the guidelines agree that watchful waiting is appropriate for men with shorter life expectancy or those who are not candidates for curative treatment. For example, the NCCN recommends an observation/watchful waiting approach for any prostate cancer patient with under 10 years life expectancy, especially if the cancer is low-riskThe AUA likewise notes that watchful waiting is appropriate for elderly patients or those with serious comorbidities when prostate cancer is unlikely to impact their lifespan. One summary puts it simply: for patients with limited life expectancy (for instance, <5 years) and low-risk cancer, watchful waiting may be more appropriate than active surveillanceemedicine.medscape.com

In higher-risk cancers, AUA guidelines explicitly recommend watchful waiting if life expectancy is <5 years

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because aggressive treatment wouldn’t add years to their life in that context.
Global Consensus: Across different organizations (NCCN, AUA, EAU, and others), the core message is consistent – use active surveillance for men who could benefit from delayed curative treatment, and reserve watchful waiting for those who likely won’t benefit from treatment. The exact cutoff in years can vary slightly (some say <10 years, some <5 years for watchful waiting), but the principle is the same. Curative intent monitoring for those likely to live longer; comfort-oriented observation for those who won’t.
Emphasis on Individual Decision: Guidelines also highlight that whether to pursue active surveillance or not should be a decision made after discussing patient preferences. No matter what the recommendations, a man’s personal values and comfort level should be considered. For instance, if a low-risk patient is extremely anxious about having cancer, he might choose treatment instead of surveillance – and that’s okay if it’s an informed choice. Conversely, a patient might opt for surveillance even if slightly higher risk, valuing quality of life over the absolute smallest chance of spread. Doctors are advised to use shared decision-making tools to help patients understand these options.

How Are These Strategies Used in Real Life?

In the real world, the use of active surveillance has grown significantly in the past 10 years, while watchful waiting is used in specific scenarios. Here are some trends and patterns from recent data:

Active Surveillance is increasingly common: A decade or two ago, most men – even with low-risk prostate cancer – were treated right away with surgery or radiation. That has changed. Today, active surveillance is the most common management for low-risk prostate cancer in many places sciencedaily.com

For example, a large study of U.S. urology practices found that the rate of active surveillance for low-risk patients rose from about 26% in 2014 to nearly 60% by 2021 pmc.ncbi.nlm.nih.gov That means more than half of eligible men are now avoiding immediate treatment and opting to be monitored instead. In some regions (like parts of Europe), even over 80% of low-risk patients go on surveillance now

medicaljournalssweden.se

This is a big shift in practice towards a more conservative approach for low-risk disease.
Variation in practice: Despite overall increases, there’s still a lot of variation. Some doctors or hospitals put almost all low-risk patients on surveillance (nearly 80–100% in certain practices), whereas others still treat many of them immediately. This variation can depend on doctor experience, patient preferences, or regional habits. Efforts are ongoing to educate and encourage consistent use of active surveillance where appropriate, because it’s considered a best practice to avoid overtreatment.
Watchful Waiting usage: Watchful waiting is harder to measure from databases, because it often isn’t a formal “treatment” entry – it’s basically doing nothing active. However, we know that watchful waiting is commonly used for older men. For instance, many men over a certain age with low-risk cancer might simply be observed by their primary doctor or urologist with minimal tests. Guidelines recommend watchful waiting for low-risk patients with <5–10 year life expectancy, and indeed many such men are managed that way. However, interestingly, some recent research has found that a significant number of older men with higher-risk cancers are still being treated aggressively, contrary to guidelines. In a study of Veterans Affairs patients, men over 70 with intermediate or high-risk prostate cancer and short life expectancy were often given surgery or radiation, even though they might not live long enough to benefit. This suggests that there is still some overtreatment happening in practice – doctors and patients may err on the side of doing something, even when observation might be wiser. The medical community is trying to address this by reinforcing that “less can be more” in certain cases of prostate cancer.
Patient choices: In real-world scenarios, patient preference plays a big role in these strategies. Some patients, when told their cancer is low-risk, feel relieved and readily choose active surveillance. Others might feel uneasy knowing there’s cancer inside them and choose to treat it for peace of mind, even if statistics say it’s safe to watch. On the flip side, an older patient might refuse treatment because he’s more afraid of surgery/radiation side effects than the cancer itself. So, while guidelines give a framework, the actual use of AS or WW is often a result of a personal decision-making process between the patient and doctor. Doctors report that once patients understand the nature of a low-risk prostate cancer, many are comfortable with surveillance – which is why its use has gone up. But addressing anxieties and misconceptions is key.

In summary, active surveillance has become a mainstream approach for low-risk prostate cancer in the past decade (with usage climbing rapidly), and watchful waiting remains an important but more selectively used approach for men who likely won’t benefit from treatment. There’s a trend toward trying to avoid unnecessary treatment across the board, but also recognition that we should not overtreat those who won’t benefit.

How Do the Monitoring Protocols Differ?

Because active surveillance and watchful waiting have different goals, the follow-up routines for each are quite different. Here’s how monitoring typically works for each approach:

Active Surveillance Monitoring: If you are on active surveillance, you will have a structured schedule of tests and visits. The exact plan can vary by doctor or guideline, but generally:
- PSA blood tests (to measure the prostate-specific antigen level) are done regularly – often about every 6 months. Early on, some doctors may do it every 3-4 months, then space to 6 months if things are stable. PSA is a marker that can indicate if the cancer is becoming more active.
- Digital rectal exams (DRE) might be done by the doctor about once a year or every other year. This is to feel if the prostate has any new lumps or changes.
- Prostate biopsies are a key part of surveillance. A biopsy means taking small samples from the prostate with a needle to check for any upgrade in cancer aggressiveness. Usually, there is a confirmatory biopsyabout 6–12 months after starting surveillance (to double-check that the cancer is indeed low-risk and we didn’t miss anything). After that, many protocols do a biopsy every 1 to 3 years as long as things remain stable. Some newer protocols may extend to 4-5 years if everything looks very low risk, but periodic biopsy is generally recommended because it’s the surest way to know if the cancer has changed.
- Imaging tests like MRI scans of the prostate are increasingly used. An mpMRI (multi-parametric MRI)can visualize the prostate and help spot any areas of concern. On active surveillance, you might get an MRI at the start (to make sure there are no hidden higher-grade tumors). You may also get follow-up MRIs if there’s a PSA rise or before a scheduled biopsy, to target any suspicious area. Some doctors even use MRI in place of routine biopsies in certain cases, though guidelines say MRI should complement, not fully replace, biopsies for surveillance.
- Clinic visits and symptom checks happen periodically. The doctor will ask about any new symptoms (like urinary changes, pain, etc.) at each visit. Typically, on active surveillance you’ll see your urologist perhaps 2 times a year (to review PSA results and overall status) auanet.org
  
  . If all is stable, these are brief check-ins; if something is concerning, they will schedule further tests or discuss treatment.
- Possible new tests: In some cases, other tools like genomic tests on the biopsy tissue might be used at the beginning to confirm the cancer is low-risk biologically. But these are optional and not routine for everyone. The mainstay remains PSA, exam, biopsy, and imaging as needed.
So, active surveillance is an active process. It can sometimes feel like a lot of appointments, but generally it’s spread out (e.g., blood tests twice a year, one scan or biopsy every couple of years). The aim is to catch any progression early so that if the cancer does start to become more aggressive, treatment can still cure it in time. Many protocols will continue surveillance until about age 75–80, after which the approach might be relaxed (shifting more to watchful waiting) because at that point the patient’s life expectancy is shorter pmc.ncbi.nlm.nih.gov

Watchful Waiting Monitoring: If you are on watchful waiting, the follow-up is much less intensive:
- No strict schedule of PSA tests or biopsies: In watchful waiting, doctors do not schedule regular biopsies or frequent PSA tests. In fact, the AUA notes that watchful waiting “does not involve routine cancer surveillance” auanet.org
  
  You might still get an occasional PSA test during a general check-up, but it’s not at the core of the plan. The idea is not to look too hard for changes, because we’re not planning to cure the cancer anyway.
- Check-ups are typically “as needed”: Often, patients on watchful waiting will see their doctor only if they develop symptoms. Some physicians might schedule yearly or semi-annual visits just to ask “how are you feeling?” and do a basic exam, but nothing invasive. Others might even manage it over phone calls. Essentially, the monitoring is symptom-driven.
- Monitoring symptoms: The kinds of symptoms doctors watch for include urinary difficulties (like trouble urinating, blockage), bone pain, weight loss, or other signs that the cancer might be advancing or spreading. If such symptoms appear, it triggers an evaluation (for example, imaging to see if cancer has spread to bones, etc.). Until then, the patient is mostly left alone.
- No routine imaging or MRI: Unlike active surveillance, watchful waiting doesn’t involve periodic MRIs. There’s no point exposing the patient to scans or biopsies if we already know we wouldn’t do curative treatment based on the results.
- Essentially, “doing nothing” until needed: Some refer to watchful waiting as “observation only.” It really means the patient continues with his life without interventions, and the medical team will step in only if the cancer declares itself by causing problems.
  
  Comparing the two: Active surveillance = regular plan (blood tests, exams, and maybe a biopsy every so often). Watchful waiting = no regular plan, just staying alert to symptoms. One source summed it up well: Active surveillance has a predefined schedule of follow-ups (PSA, DRE, MRI, biopsies), whereas watchful waiting follow-up is patient-specific and depends on symptom development. This means on active surveillance you’ll be in and out of the doctor’s office routinely, but on watchful waiting you might go years without any cancer-related test unless something changes.

Benefits and Risks: Weighing the Two Approaches

Both active surveillance and watchful waiting have advantages and potential downsides. It’s important to understand these to make an informed decision. Below, we break down the pros and cons of each approach:

Benefits of Active Surveillance

Avoids or delays side effects: The biggest benefit is that you can delay treatment (surgery or radiation) and thus avoid side effects like urinary incontinence or erectile dysfunction for as long as possible – maybe forever sciencedaily.com

Many men on surveillance never need treatment, so they keep their quality of life intact without ever experiencing those treatment-related issues.
Peace of mind that cancer is monitored: Some patients find comfort that, although they are not treating the cancer immediately, their doctors are keeping a close watch on it. They have frequent check-ins and know that if anything changes, it will be caught early. This can reduce anxiety compared to doing nothing at all.
Similar survival as immediate treatment for low-risk disease: For low-risk prostate cancer, studies (including a 15-year clinical trial in the UK) have shown that active monitoring yields the same extremely high survival rates as immediate treatment. In that trial, after 15 years, over 96% of men who chose active monitoring were still alive from prostate cancer, which was virtually the same as those who had surgery or radiation upfront. This means choosing surveillance does not compromise your chance of long-term survival when the cancer is truly low-risk. You’re not more likely to die of cancer by watching it carefully and treating only if needed.
Opportunity to use new advances: By waiting on treatment, you remain eligible for new technologies that might come along. For example, over the last decade, tools like better MRI scans and genomic tests have emerged to guide prostate cancer care. If you are on AS for say 5–10 years, and then the cancer needs treatment, the treatment options or precision might be even better by then.
Personal empowerment: Some men feel that active surveillance gives them a sense of control – they are actively making a choice to manage their cancer in a smart way. They focus on healthy lifestyle and knowing their cancer’s status, instead of rushing into the operating room. This can be psychologically beneficial for those who prefer to avoid aggressive interventions.

Risks or Drawbacks of Active Surveillance

Need for regular tests and biopsies: Active surveillance is not a “free pass.” It comes with the burden of frequent medical appointments and procedures. Repeated PSA tests (blood draws) are easy, but prostate biopsies can be uncomfortable or carry small risks (like bleeding or infection). Some men find the biopsy procedure painful or stressful. Over years, having multiple biopsies is something to consider. There’s also a small risk each time – for example, a risk of infection requiring antibiotics or hospitalization (though rare).
Anxiety of living with cancer: Not everyone is emotionally comfortable knowing they have cancer inside and they are “doing nothing” to remove it immediately. Even with close monitoring, worry can be a big downside. Patients might feel anxious every time they await their PSA result or biopsy result, fearing bad news. This anxiety can affect quality of life for some, to the point where they prefer to just treat the cancer. It’s important to assess your own comfort level – some people cope well, others lose sleep over it.
Small risk of missing the window of cure: Active surveillance tries to catch any change in the cancer early, but there is a small chance the cancer could grow or spread in between check-ups. Perhaps the initial biopsies missed a higher-grade area, or over time the tumor mutates to a faster form. If the cancer progresses silently and isn’t caught soon enough, it might reduce the chance of curing it when treatment finally happens. This scenario is not common for low-risk, but it’s the main “medical” risk of surveillance. Studies show it’s only a small percentage of cases where this happens, but it’s not zero. For instance, a man might go from very low-risk to a more aggressive disease that has begun to escape the prostate between scheduled tests. The protocols are designed to minimize this risk, but it can’t be eliminated entirely.
Eventually, many still get treatment: Choosing AS now doesn’t guarantee avoiding treatment forever. In various studies, anywhere from 25% to 50% of men on active surveillance end up getting active treatment within 10-15 years due to signs of progression. So, you might ultimately face surgery or radiation down the road. By that time you’ll be older, which can make surgery a bit harder to recover from (though still usually safe). Some men might feel they “delayed the inevitable” and wonder if it would’ve been better to just treat when younger. However, it’s worth noting they spared themselves years of side effects in the meantime. Still, it’s a consideration: you may be trading “treatment now for maybe treatment later.”
Diligence required: Active surveillance only works if you stick to the plan. Missing appointments or neglecting follow-up is dangerous because then you’re not truly monitoring. The responsibility is on the patient and healthcare team to be vigilant. This requires good communication, access to medical care, and a bit of commitment. Not everyone has the means or discipline for that (for example, if someone lives very far from medical facilities, it might be hard to do frequent follow-ups).

Benefits of Watchful Waiting

Maximized quality of life and comfort: Watchful waiting means no active intervention, so the patient avoids all treatment side effects and even testing discomfort altogether. Especially for an older man, this can mean his remaining years are spent without the stress of treatments. In plain terms, he is left in peace unless something truly bothers him. This approach maintains day-to-day quality of life to the highest degree initially, because nothing is done to disrupt it.
No frequent hospital visits or procedures: For someone with other health issues, not having to go to multiple appointments for cancer can be a relief. Watchful waiting simplifies medical care – often it’s just managed by occasional check-ins. The patient can focus on other aspects of his health or life without a rigorous cancer schedule.
Avoids overtreatment in those unlikely to benefit: If a man is unlikely to live more than a few years or has a very slow cancer, watchful waiting ensures he won’t undergo unnecessary surgery or radiation that wouldn’t extend his life. It is a wise, conservative choice that can prevent unneeded suffering from treatment in these cases. As one guideline notes, the critical goal is to avoid reducing quality of life with treatments that won’t help the patient live longer. Watchful waiting achieves that goal.
Flexibility to shift gears if needed: Although there’s no routine monitoring, the patient is not abandoned. If the cancer does start causing symptoms, the medical team will step in and provide appropriate therapy (like hormone treatments to shrink the tumor or radiation to relieve bone pain). So, there is a safety net: the patient will get care when it’s truly needed. Many cancers under watchful waiting never reach that point, meaning the patient never has to be treated at all in his lifetime. But it’s good to know that if something changes, doctors can address issues to keep the patient comfortable.

Risks or Drawbacks of Watchful Waiting

Possibility of cancer progression without warning: Since watchful waiting doesn’t involve regular tests, the cancer could be growing or spreading silently and one might not know until it causes significant symptoms. By that time, it could be quite advanced (for example, metastasized to bones). At that point, it would be too late for cure, and sometimes even controlling symptoms can be more challenging if the disease is widespread. Essentially, with WW the cancer is given free rein until it makes itself known. This is acceptable if the patient wasn’t expected to live long anyway, but if misjudged, it could shorten life.
No intent to cure the cancer: A downside is accepting that you are forgoing the chance of cure. Watchful waiting is explicitly palliative – meaning it’s only to ease symptoms if they occur, not to eliminate the cancer. For some, this is hard to accept emotionally (“doing nothing while having cancer”). And if the patient’s health status changes (say he outlives his life expectancy projection and is now healthier than expected), he might regret not treating the cancer earlier when it was curable. Once you choose WW and the cancer progresses, you usually can’t go back and cure it; that window may close.
Potential for future symptoms and emergency interventions: By not treating early, the cancer might eventually cause issues like urinary blockage or bone fractures from metastases in some men. These situations might force an urgent intervention (like a procedure to open urinary blockage or radiation to a painful bone lesion). Dealing with these later can be harder on an older, frailer patient. In contrast, treating the cancer earlier could have prevented those scenarios. So there’s a trade-off: fewer interventions now may lead to more serious interventions later, albeit aimed at comfort.
Uncertainty for patient and family: Some patients and their families feel uneasy with watchful waiting because it can feel like a “ ticking time bomb” even if rationally it’s not likely to explode. There’s a level of psychological uncertainty – what if the doctors are wrong and the cancer gets bad fast? Family members might worry that their loved one’s cancer isn’t being “handled.” This can cause stress in itself. Proper understanding is important: knowing that in many cases (especially low-risk in older patients) the cancer truly may never become a serious problem. But not everyone is comfortable with the gamble, however small it is.
Lack of monitoring (missed opportunities): With no periodic check-ups focused on the cancer, there’s also a chance other aspects (like general health optimization or timely discovery of progression) are not addressed. Some argue that even older patients benefit from at least some monitoring (like a PSA test once a year) just to make sure nothing unusual is happening. Watchful waiting in its purest form might miss that, though often doctors do a minimal observation. In any case, the patient is basically hands-off, which requires trust that this is safe.

In short, Active Surveillance offers a middle ground – high chance of avoiding treatment side effects and equal survival for low-risk cases, at the cost of some regular tests and slight anxiety. Watchful Waiting offers maximum initial comfort and no medical meddling, at the cost of potentially higher risk later if the cancer acts up and the acceptance that it won’t be cured.

Neither approach is “bad” – each has its context where benefits outweigh risks. It’s all about matching the approach to the patient’s situation.

Patient Perspectives and Considerations

Deciding between active surveillance, watchful waiting, or immediate treatment is a personal decision that should be made with a doctor’s guidance. Here are practical insights and factors for patients to consider when choosing a monitoring strategy:

Age and Life Expectancy: Think about how long you are likely to live (with and without the cancer). If you are relatively young and healthy, you have many years ahead where cancer could potentially progress – so active surveillance might be wiser to keep tabs on it. If you are older or have serious medical issues (heart, lung problems, etc.), you might not need any intervention for the cancer – watchful waiting could spare you unnecessary treatment. For example, an 50-year-old man and an 85-year-old man with the exact same tumor might make opposite decisions because of their age difference.
Cancer Risk Level: Discuss with your doctor what risk category your cancer falls into. Is it very low risk, low risk, intermediate, or high? Low-risk and very low-risk cancers are the prime candidates for surveillance. If your cancer is higher risk (more aggressive features), active surveillance might not be safe unless there are strong reasons (like you can’t undergo treatment). High-risk cancers are usually treated, unless you truly cannot tolerate therapy, in which case it becomes watchful waiting with a focus on quality of life pmc.ncbi.nlm.nih.gov

Knowing the grade and stage of your cancer helps guide the choice – make sure you understand if yours is the “kind that almost never causes trouble” or the “kind that could be dangerous.” This is a critical factor in the decision.
Health Status and Other Conditions: Take into account your overall health. If you have multiple health issues, major surgery or radiation might pose more risk or strain. Those who have other illnesses may lean towards less intervention (like surveillance or observation). On the other hand, if you’re very healthy aside from the cancer, you could handle treatment later if needed, making surveillance a comfortable initial route. Doctors often use life expectancy calculators to help make this call, but these are estimates. It’s basically balancing cancer risk vs. other health risks.
Personal Comfort and Anxiety: Know yourself emotionally. Would you be at peace knowing the cancer is there as long as it’s closely watched, or would that knowledge eat at you with worry? There’s no right or wrong feeling – some people are natural “watchers,” others are “fighters.” If you think you’d be constantly anxious on active surveillance, despite reassurance, it’s worth discussing. A small percentage of men on AS choose to get treatment eventually primarily because of anxiety or preference, even if the cancer hasn’t changed. On the flip side, if the idea of surgery and its side effects scares you more than the cancer, you might prefer surveillance or watchful waiting. Honest communication about your comfort level with each approach is key. It might help to talk to other men who have done surveillance or treatment to hear their experiences.
Willingness to Follow Up: Active surveillance is a commitment. Are you willing to go to the doctor regularly and possibly have multiple biopsies? If you tend to skip appointments or live far away and can’t come often, surveillance might not be ideal unless you can make arrangements. Ensure you’re up for the task of sticking with the monitoring schedule. If not, and you’re a good candidate for cure, it might actually be safer to treat the cancer than to do surveillance poorly. For watchful waiting, you need to be attentive to your body and report any symptoms promptly – and keep at least occasional contact with your healthcare provider. Consider your lifestyle and reliability in medical follow-ups when choosing.
Understanding of the Disease: Take time to truly understand your prostate cancer. Have the doctor explain: How aggressive is it? How likely is it to grow or spread? If it’s the type that is very unlikely to ever bother you (like many small Gleason 6 tumors), that knowledge can be reassuring and make active surveillance feel right. If it’s borderline, understand what signs would trigger treatment. Knowledge is power – patients who grasp why their cancer can be safely watched often feel more confident in doing so. Don’t hesitate to ask questions or even seek a second opinion if unsure.
Support System and Values: Talk with your family or loved ones about your options. Sometimes a spouse or family member’s comfort with the plan is important too, since they will be involved in your care and emotional support. Also, reflect on your values: Is it more important to you to avoid any chance of cancer spread, no matter how small, or to avoid treatment side effects as much as possible? Everyone weighs these differently. There is also the consideration of future plans – for example, a younger man who wants to remain potent to have children might favor surveillance to avoid treatment that could affect fertility or sexual function, whereas another man might prioritize eliminating cancer over those concerns. Clarify what matters most to you.
Practical Considerations: If you choose active surveillance, make sure you go to a center or doctor experienced in it, if possible. High-quality monitoring (with good imaging, labs, etc.) can make a difference. If you are far from a facility that can do MRI or you don’t have easy access to a urologist, think how you’d manage the logistics. If you choose watchful waiting, ensure your primary care doctor and family are aware of the plan, so they don’t push you into unnecessary action out of misunderstanding. In either case, clear documentation of your plan in your medical records is helpful.
The option to change your mind: Remember, choosing a monitoring strategy is not an irreversible decision. You can start with active surveillance and later decide to have treatment even if the cancer hasn’t changed, if you feel uneasy. You can also switch from surveillance to watchful waiting as you get older or if other health issues arise (essentially “graduate” to watchful waiting when curative treatment no longer makes sense). The opposite is also true: if you choose watchful waiting but then new health advances or personal feelings lead you to seek treatment, you can discuss if it’s still feasible. In some cases, a patient on WW might later opt for therapy if, say, a new minimally invasive treatment becomes available that they feel comfortable with. Stay flexible and in communication with your healthcare providers. They will support you in whatever approach is consistent with your health and wishes.

Helping Patients Make the Right Choice

For patients facing this decision, here are a few practical tips to arrive at the approach that’s best for you:

Have a detailed talk with your urologist: Ask your doctor to clearly explain why they recommend one approach over the other in your specific case. Have them spell out the chances of the cancer causing harm if untreated versus the potential side effects of treatment. If something isn’t clear, ask again. This conversation is crucial. Don’t be shy about bringing a list of questions.
Consider a second opinion: Especially if you’re unsure or uncomfortable with the advice, seeing another specialist can help. Another doctor might explain things differently or confirm the plan. Many men with low-risk prostate cancer get second opinions at large cancer centers regarding active surveillance eligibility – this can provide peace of mind that “watching is okay.”
Use educational resources: Reliable resources like the American Cancer Society (cancer.org) or prostate cancer foundations have literature on active surveillance vs treatment. Reading patient stories or reputable Q&A can give perspective. Just be careful with random internet info – stick to trusted sources. Some organizations have decision aids that walk you through the pros and cons in an interactive way.
Involve your loved ones: Bring your spouse, partner, or a family member to appointments. They can help remember information and provide support. Sometimes they will think of questions you didn’t. Making sure those close to you understand the plan will help create a support network, especially if the plan is surveillance (so they don’t constantly worry or pressure you to “do something” when doing something isn’t needed).
Think about your future self: One way to decide is to imagine yourself 5 or 10 years from now. If you choose active surveillance, and 5 years later you still haven’t needed treatment and feel healthy, how will you feel about that choice? Versus if you choose immediate treatment and are dealing with side effects, will you regret not waiting? Or vice versa: if you choose surveillance and later needed a bigger treatment, would you wish you had treated earlier? This kind of future scenario thinking can sometimes clarify what choice you’re most comfortable with.
Know that doing nothing can be the right thing: Culturally, we often feel we must “fight” cancer immediately. It’s important to understand that **choosing not to treat right away is an active, valid choice, not a neglectful one. Both active surveillance and watchful waiting are endorsed by experts and backed by research for appropriate patients. You are still taking care of your health by choosing these routes. It’s about doing what is medically best, not doing “nothing.” As one expert said, it’s about avoiding harm from unnecessary treatment without shortening life. Reframing it this way can help you feel confident if you opt for a monitoring strategy.
Keep communication open: Whatever you choose, keep talking with your doctor. If you’re on active surveillance, ensure you get your results explained every time and ask “what does this mean for me now?” If you’re on watchful waiting, report new symptoms sooner rather than later. Good communication can catch any issues at the right time and also reassure you when things are stable.

Final Thoughts:

Every prostate cancer patient is unique. Active surveillance and watchful waiting offer alternatives to immediate treatment that can spare men from side effects while still keeping them safe. Active surveillance is like a safety patrol, ideal for men with low-risk cancer who likely have many years ahead – it watches the cancer carefully and keeps the door open for cure if needed. Watchful waiting is more like placing the cancer in the backseat, used when a man’s remaining years are few or the cancer is truly not a threat – it forgoes aggressive checks and focuses only on treating symptoms if they arise.

Both strategies have been proven effective in the right situations, and guidelines from 2015 through 2025 strongly support their use to avoid overtreatment. The key is selecting the right approach for the right patient. By understanding the differences, benefits, and risks of active surveillance versus watchful waiting, patients (and their families) can make informed decisions in partnership with their doctors. Remember, the goal is to maximize your length and quality of life – sometimes that means treating the cancer aggressively, and other times it means watching and waiting wisely. Always choose the path that aligns with your medical needs and your personal values.

In summary: If you have a low-risk prostate cancer and are expected to live many more years, active surveillancelets you delay treatment safely and avoid side effects, with frequent monitoring to catch any change pmc.ncbi.nlm.nih.gov. If you are older or have serious health issues and the cancer is not likely to threaten your life, watchful waitingallows you to enjoy life without interventions, checking in only if problems develop. Take the time to discuss these options with your healthcare team. With clear information and support, you can confidently choose the approach that’s right for you.

Sources:

National Comprehensive Cancer Network (NCCN) Guidelines – Prostate Cancer (2023)

pmc.ncbi.nlm.nih.gov
American Urological Association (AUA) Guidelines – Clinically Localized Prostate Cancer (2022)

auanet.org

auanet.org
European Association of Urology (EAU) Guidelines – Prostate Cancer Active Surveillance vs Watchful Waiting Definitions

www1.racgp.org.au
Daskivich et al., JAMA Internal Medicine (2024) – Study on overtreatment in older men

sciencedaily.com
Klotz et al., (2015) – Active Surveillance 15-year outcomes
Hamdy et al., NEJM (2023) – ProtecT trial 15-year results (monitoring vs treatment)

ascopost.com
RACGP (Australia) Clinical Update (2024) – “When less is more: updates in AS and WW”

www1.racgp.org.au

www1.racgp.org.au