“Active Surveillance,” also called, “Watchful Waiting” or “Vigilance,” in Malecare groups, is based on the premise that cases of localized prostate cancers may advance so slowly that they are unlikely to cause men – especially older men – any problems during their lifetimes. Some men who opt for watchful waiting, also known as “observation” or “surveillance,” have no active treatment unless symptoms appear. They are often asked to schedule regular medical checkups and to report any new symptoms to the doctor immediately.
Is active surveillance the same as watchful waiting?
No, it is very different. Watchful waiting aims to avoid treatment unless symptoms develop. Then, when treatment starts, it is aimed at controlling the cancer rather than getting rid of it. Watchful waiting can be suitable for men with other health problems or who may be less able to cope with treatment.
If men on watchful waiting get symptoms, such as problems passing urine or bone pain, their cancer can be controlled with hormone therapy.
Watchful waiting involves less monitoring than active surveillance and is often carried out by your GP rather than your specialist team at the hospital.
If watchful waiting has been recommended as an option for you but you would prefer a different treatment, you should discuss this with your specialist.
Active surveillance involves monitoring your prostate cancer with regular tests, rather than treating it straight away. The tests aim to find any changes that suggest that the cancer may grow and cause symptoms. Treatment can then be offered at an early stage, with the aim of getting rid of the cancer completely.
Watchful waiting has the obvious advantage of sparing a man with clinically localized cancer- who typically has no symptoms- the pain and possible side effects of surgery or radiation. On the minus side, watchful waiting risks decreasing the chance to control disease before it spreads, or postponing treatment to an age when it may be more difficult to tolerate. Of course, treatments may also improve over time if watchful waiting is chosen. Another potential disadvantage is anxiety; some men don’t want the worry of living with an untreated cancer.
Who can have active surveillance?
Active surveillance is suitable for men with low risk early stage prostate cancer that is contained within the prostate gland (localised prostate cancer). It may also be suitable for some men with medium risk cancer, and your specialist will discuss whether it is an option for you. High risk cancers are not suitable for active surveillance.
Men with low risk cancer will have a PSA level of less than 10 ng/ml and a Gleason score of six or less. The biopsy result should show that there was cancer in less than half of the samples taken. Medium risk cancer is a PSA level of 10-20 ng/ml or a Gleason score of 7 (3+4)
The most obvious candidates for watchful waiting are older men whose tumors are small and slow growing, as judged by low grade/ Gleason score and low stage.
Many men who choose watchful waiting live for years with no signs of disease. A number of studies have found that, for at least 10 or even 15 years, the life expectancy of men treated with watchful waiting (primarily older men with less lethal forms of prostate cancer) is not substantially different from the life expectancy of men treated with surgery or radiation-or, for that matter, of the population at large.
Your urologist may also consider the amount of cancer cells found in each sample taken during the biopsy. Active surveillance may be suitable if you have a small amount of cancer cells in the samples.
There are some other tests that you may have to help decide whether active surveillance is suitable for you, but these are much less common and you may not be offered them. (see the malecare.org section on tests. These are:
- Measuring your PSA density
- A free and total PSA test
Scandinavia and a number of other areas in Europe, watchful waiting had been used for low-grade prostate cancer patients who have early stage disease. This is no longer true. Watch Waiting in Europe is now on par with the United States. Watchful waiting, or observation-deferred treatment, is a strategy in which a patient is monitored periodically but receives no treatment. Generally this strategy is advised for older men with limited life expectancy, those with localized prostate cancer who do not want to experience the side effects of conventional treatment, and those who have cancers that are not likely to kill them. Although there are certainly arguments in this country regarding observation, the disease specific survival figures do support a place for observation depending upon the stage, grade, and age of the patient.
The question of whether to watchful wait or treat prostate cancer will continue to be asked until there are definitive answers from clinical trials, such as the Prostate Cancer Intervention Versus Observation Trial (PIVOT study). This multi-institutional cooperative study involves comparing early or clinical localized prostate cancer patients who undergo radical prostatectomy or watchful waiting alone (by a randomization process). This study will monitor and report patients in terms of progression-free survival, freedom from metastatic disease, disease-specific survival, and overall survival, as well as quality of life. The results will not be evident until approximately 2008, but 5 years into the study, no survival advantage has been noted in either arm.