Active surveillance is a strategy for localised prostate cancer care that consists of regularly monitoring the disease without initiating treatment for an immediate cure (surgery, radiotherapy or focal treatment). It aims to avoid unnecessary treatment of non-aggressive cancers while maintain the option of intervening if the cancer develops.
Active surveillance is suitable for patients with a prostate cancer that is considered to be low risk. A number of criteria are applied in deciding which patients could be candidates for this treatment strategy:
- Gleason Score 6 or 7 (grade ISUP 1 or 2) for prostate biopsy.
- PSA < 10 ng/mL.
- Cancer confined to the prostate (stage T1-T2).
- A sufficient life expectancy (> 10 years) to justify prolonged monitoring.
Active surveillance is based on rigorous and structured medical monitoring, including :
PSA test every 3 to 6 months to monitor biological changes.
Regular digital rectal examinations to assess local development.
Annual MRI of the prostate to detect any radiological changes.
Regular biopsies of the prostate (generally every 2 or 3 years) to confirm the absence of aggressive development.
In the event of an unfavourable development (significant increase in PSA level, cancer progression revealed by biopsies or MRI) or if the patient so prefers, curative treatment can be proposed.
Active surveillance enables patients to maintain their quality of life while avoiding or delaying potential side effects (urinary incontinence, erectile dysfunction, anejaculation, etc.) associated with the various treatments. It does not bring any lessening of cure prospects as a curative treatment can be initiated rapidly if the disease progresses. What is more, studies have not shown any benefits in terms of overall survival if patients with a low risk prostate cancer are treated immediately.
Active surveillance involves certain risks, most notably that of the cancer progressing, that is, a cancer that escapes the prostate. Long-term data nevertheless suggest that this risk represents between 5% and 10% of patients after a follow-up of 15 years and probably less since the systematic use of MRI and biopsies guided by MRI. The importance of rigorous monitoring and an extremely precise initial biopsy evaluation must be stressed, however. The latter, ideally associated with MRI, makes it possible to ensure that the patient corresponds effectively to the low risk criteria and that there has been no under estimation of a more aggressive cancer.
Finally, certain patients may experience anxiety due to the diagnosis, the absence of active treatment, the wait for PSA results or the need for repeated biopsies. This anxiety can be increased by the fear of potential side effects, such as bleeding or infection, even if these complications are rare.
See our technical note on prostate biopsy
Combating overtreatment
Prostate cancer is the most common form of cancer in men, but it often develops slowly, especially the low risk forms. With the improved detection tools, notably PSA testing and easy access to MRI, a growing number of localised and non-aggressive prostate cancers are detected. A significant proportion of these cancers will never develop to a clinically significant degree during the patient’s life.
In this context, many patients are exposed to curative treatment (surgery, radiotherapy or focal therapy) that, although effective, can result in important side effects such as urinary incontinence or erectile dysfunction. This phenomenon, known as overtreatment, is a major issue as it affects the quality of life without improving overall survival.
Active surveillance was developed as a response to this problem by offering a safe alternative suitable for patients with a low risk prostate cancer. This strategy makes it possible to avoid unnecessary treatment while maintaining the quality of life of patients subject to regular monitoring.