Being told you have cancer and then being told the plan is to watch it produces a particular kind of unease. It sounds like inaction, or like being placed at the back of a queue. For most men the instinct after a prostate cancer diagnosis is to have it removed, and the harder conversation is often the one explaining why that may not be the better choice.
Active surveillance exists because prostate cancer is not one disease with one behaviour. Some prostate cancers grow quickly and require prompt treatment. Many others grow so slowly that they will never cause symptoms or shorten life, and treating them delivers all of the side effects of treatment with none of the benefit. Distinguishing between the two is the central task, and modern assessment does it reasonably well.
What Active Surveillance Is
Active surveillance is a structured monitoring program with defined tests at defined intervals and clear criteria for when to change course. It typically involves PSA testing at regular intervals, periodic examination, MRI of the prostate, and repeat biopsy at intervals determined by the individual picture. It is not the same as watchful waiting, which is a different and more conservative approach used for men whose age or other health conditions mean treatment would not be appropriate under any circumstances.
The purpose is to remain in a position where curative treatment is still fully available. If the cancer shows signs of becoming more aggressive — a rising PSA pattern, a change on imaging, a higher grade on repeat biopsy — the plan moves to treatment, and the outcomes for men who convert from surveillance to treatment are comparable to those who were treated immediately.
Who It Suits
Surveillance is generally offered for cancers assessed as low risk: a low grade on biopsy, a relatively low PSA, and limited disease on imaging and sampling. Some men with favourable intermediate-risk disease are also candidates, depending on the details and on their overall health and life expectancy.
It is not offered for higher-grade or more extensive disease, where the balance shifts clearly toward treatment. The assessment involves the biopsy grading, PSA and its behaviour over time, MRI findings, family history, and increasingly genomic testing of the biopsy tissue in selected cases. Family history and ancestry matter here, since prostate cancer in men of African or Caribbean descent tends to behave more aggressively.
What It Asks of You
The trade-off is honest and worth stating. Surveillance avoids or delays the side effects of surgery and radiation — principally erectile dysfunction and urinary incontinence, both of which are common after treatment and can be lasting. In exchange it requires ongoing appointments, repeated PSA tests, periodic MRIs and occasional repeat biopsies, indefinitely.
It also requires living with a cancer diagnosis. That is not a small thing, and it is the part most often underestimated at the outset. Some men find the monitoring reassuring; others find each PSA result an event they dread for weeks beforehand. Anxiety about recurrence and about the decision itself is common and legitimate, and it is a reasonable thing to raise, since persistent anxiety is treatable and occasionally it is what drives a man toward treatment he did not otherwise need.
A meaningful proportion of men on surveillance eventually move to treatment, and a meaningful proportion never do. Neither outcome represents a failure of the approach. What matters is that the decision is made with a clear understanding of what each path involves, and that the monitoring, once agreed, is actually attended.
Dr. Raymond Nash provides prostate assessment, PSA interpretation and ongoing urological care at Grande Prairie Men’s Medical Clinic, and where the diagnosis is weighing heavily, Dr. Isaac Klein can address that alongside it in the same clinic. Appointments: gpmm.clinic or (587) 416-8296. This article is general information and is not a substitute for advice about your own diagnosis.