For some patients, their prostate cancer grows very slowly and progresses so slowly that treatment is not even necessary. However, it is still important for physicians to keep a close eye on them so that they can intervene in a timely manner if the disease worsens, an approach known as active surveillance or watchful waiting.
When physicians recommend active monitoring or watchful waiting, they usually do so based on consideration of the following:
- The patient is older;
- Companying other medical conditions, such as heart disease, diabetes, or long-term hypertension;
- The risks and side effects associated with the treatment outweigh the benefits;
- The tumor is still small;
- The patient has no discomfort.
Active monitoring
Active surveillance is defined as receiving regular checkups to determine if the disease is progressing. Tests are usually done every 3 to 6 months and include:
- Rectal palpation. The doctor, wearing gloves, inserts a finger into the patient’s rectum to touch the size of the patient’s prostate, the presence of a mass, and to clarify the nature of the patient’s prostate (soft or hard) and any adhesions to surrounding tissues and organs (such as the rectum).
- Prostate-specific antigen (PSA) test. The doctor will test the patient’s blood for levels of PSA, a protein produced by the prostate gland, which is usually elevated in patients with prostate cancer.
- Imaging tests. Doctors may use different imaging tests of the patient’s prostate, such as MRI and ultrasound, to determine if the cancer has spread beyond the prostate.
- Doctors may also perform a prostate puncture biopsy, in which a small piece of tissue from the patient’s prostate is removed and the tumor is looked at under a microscope. Patients with prostate cancer may need a biopsy every year, and the first prostate puncture during active surveillance should be done within 12 months of the diagnostic puncture.
If none of these tests suggest a change in the disease, the doctor will recommend continued close observation and not recommend that the patient receive treatment.
If the test results indicate that the tumor is growing and spreading, or if the patient is experiencing discomfort, the doctor will pursue curative treatment options.
The risk of active surveillance is that there is a risk of tumor progression during the period of no treatment, which could interfere with subsequent treatment.
In addition, even if tumors grow slowly, they are still a potential threat for younger patients with long life expectancy over the next 20-30 years, so active surveillance is rarely recommended for younger prostate cancer patients.
Watchful waiting
Watchful waiting means no intervention and fewer tests are needed than active surveillance. Physicians typically recommend watchful waiting in the following situations:
- Patients with other serious underlying disease that prevents them from receiving treatment for prostate cancer.
- The patient has a short life expectancy and a slow-growing tumor that may not cause serious problems during his or her lifetime.
- If patients develop symptoms, they can discuss with their doctor whether treatment measures are needed. However, doctors usually treat symptoms to relieve pain and improve quality of life, rather than cure the cancer.
Weighing the pros and cons
Active monitoring or watchful waiting is ultimately a patient decision, but doctors will provide information and advice, such as informing patients of the possible adverse effects on their bodies if they receive surgery, radiation or chemotherapy. Sometimes the risks and side effects of treatment to the patient far outweigh the benefits of killing the cancer cells.
It is controversial whether surgery or radiation therapy is necessary for patients with prostate cancer whose tumors are growing slowly. In these patients, the choice of surgery or radiation therapy depends largely on the patient’s age and the presence of other diseases, and if the patient is very old and has a lot of disease, it may not be worth the risk for treatment.
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