When Is Watchful Waiting Safe for Prostate Cancer?

Medically Reviewed By William C. Lloyd III, MD, FACS
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After getting a prostate cancer diagnosis, 'watchful waiting' and 'active surveillance' are clinical terms you may hear from your doctor. Watchful waiting for prostate cancer means delaying treatment until you have symptoms or there are other signs the cancer is growing or changing in some way. Watchful waiting involves fewer tests and follow-up than active surveillance, which involves regularly scheduled monitoring of cancer with tests and biopsies (see below). 

Keep in mind that prostate cancer specialists are not in consensus when it comes to the definition of watchful waiting and active surveillance. Some doctors see them as one form of clinical management of the disease and do not differentiate between the two, and some doctors do not use the terms. When discussing your diagnosis and plan going forward, make sure you are on the same page with your doctor—that you understand what your doctor means by watchful waiting or active surveillance and you agree with the plan.

Good Candidates for Watchful Waiting and Active Surveillance

Watchful waiting is a reasonable approach for men with early-stage prostate cancer that seems to be slow growing, especially for men who are older than 65 or have other serious health problems. For these men, it’s not known whether surgery or radiation therapy will help them live longer. However, more research studies are necessary, comparing men of different ages and stages of cancer.

Active surveillance is also an option for small, slow-growing tumors. Treatment would begin if test results indicate a change in the tumor, or if you develop bothersome symptoms.  

Both watchful waiting and active surveillance allow you to delay or avoid the side effects of surgery, radiation therapy, or other treatments. But it can be risky. Waiting to start treatment means that you may have less of a chance to control the disease if it becomes more aggressive. Waiting could also limit your treatment options. 

Whether watchful waiting and active surveillance are safe options for you depends on these two main factors: 

  • Your Gleason score, which is the result of a lab test that analyzes the pattern of prostate cancer cells. The pattern determines the tumor’s likeliness to spread. 
  • Your tumor size and location, which you learn from the stage of prostate cancer. If it’s small and contained within the prostate, you may be a good candidate for waiting.

Your doctor’s judgment and your feelings about living with untreated prostate cancer also come into play. You need to be comfortable living with prostate cancer, even if you have a slow-growing form. Waiting may not be a good option for you if it’s causing undue stress and affects your emotional well-being.

Tests to Expect During Watchful Waiting and Active Surveillance

Although watchful waiting implies that nothing will be medically done until necessary, your doctor will still check you regularly for signs and symptoms of a change in the tumor, such as difficulty urinating.. You may have some diagnostic tests, but they will be less invasive and less frequent compared to active surveillance. These are the tests you will have: 

Prostate-Specific Antigen (PSA) Blood Test

This test measures the amount of PSA in your blood. Both normal and cancer cells in the prostate make PSA. A PSA level of less than 4 nanograms per milliliter of blood is considered healthy. Although men with a PSA lower than 4 can have prostate cancer, generally cancer develops when the PSA goes higher than 4. 

Other conditions besides prostate cancer, such as an enlarged prostate, can raise PSA levels. During watchful waiting and active surveillance, your doctor will compare your most recent PSA test result with your previous one. 

Digital Rectal Exam (DRE)

During this quick test, a doctor feels for bumps or hard areas on the prostate, which may indicate prostate cancer is growing. A DRE can also determine whether the tumor has grown outside the prostate.  

Repeat Prostate Biopsy
 
Repeat prostate biopsies are performed one year after diagnosis and every 4-5 years thereafter. Using a thin, hollow needle designed to remove tissue in a fraction of a second, your doctor will take several samples of tissue from your prostate. You may have local anesthetic for this procedure. Your doctor sends the tissue samples to a lab for testing. A pathologist will use the cells to determine your Gleason score. Your doctor compares this score with your previous score.

Your doctor may suggest treatment if your Gleason score rises, your PSA level begins to increase, or you develop symptoms. These may include:

  • Blood in the urine
  • Loss of bladder or bowel control
  • Pain in the hips, back, chest or other areas
  • Problems passing urine
  • Trouble getting an erection
  • Weakness or numbness in the legs and feet

Your Testing Schedule

Although it’s debatable how often testing should be done during active surveillance, the National Cancer Institute suggests every 3 to 6 months initially, and a repeated biopsy to recheck your Gleason score after a year. Ask your doctor how often you’ll need to have checkups, and stick to the schedule. While you’re being monitored, be sure to alert your doctor if you develop symptoms or if anything changes between checkups.

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  1. Prostate Cancer. American Cancer Society. http://www.cancer.org/cancer/prostatecancer/

  2. What You Need To Know About Prostate Cancer. National Cancer Institute. http://www.cancer.gov/publications/patient-education/wyntk-prostate-cancer

  3. Watchful waiting and active surveillance for prostate cancer. American Cancer Society. https://www.cancer.org/cancer/prostate-cancer/treating/watchful-waiting.html

Medical Reviewer: William C. Lloyd III, MD, FACS
Last Review Date: 2020 Aug 4
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