Q 1. What does active surveillance mean?
A. Active surveillance is a way of monitoring prostate cancer that is contained within the prostate
(localised prostate cancer) and with a low chance of progressing. It is an alternative to initiating immediate treatment.
The aim of active surveillance is to avoid treatment unless there are signs of the cancer
progressing. This is so that you can avoid, for as long as possible, any side effects of treatment.
Many studies have shown that with a rigorous active surveillance programme, there is no
detrimental effect for patients or an increased chance of cancer spreading.
Q 2. Who is eligible for active surveillance?
A. The criteria for Active surveillance are not well defined. The below mentioned criteria are usually followed.
Men diagnosed with low risk prostate cancer, that is a prostate specific antigen (PSA) equal to or
less than 10ng/ml, Gleason grade sum score 6 and clinical stage T1-T2 and cancer involving less
than 50% of the number of cores
or
Low volume intermediate risk cancer, that is PSA 10-20ng/ml, Gleason7 and T1-T2.
There are a few other factors such as age, family history or other illness that may also be
important when considering active surveillance.
Q 3. What does active surveillance involve?
A. An active surveillance programme may vary slightly from patient to patient, depending on your specific circumstances. Your programme will have the following schedule:
- After you have been enrolled to active surveillance, you will be seen in clinic at three months.
- All patients will have a repeat PSA, magnetic resonance image (MRI) scan of prostate (if not already done) and may be recommended to have a repeat biopsy to ensure there is only low risk disease or low volume intermediate risk disease in the prostate. This biopsy may be another transrectal biopsy or a transperineal biopsy.
- If the scans and repeat biopsy confirm low risk disease then a regular plan of three monthly PSA will be initiated and a personalised plan of follow up arranged.
- Typically, this will involve PSA blood tests.
- A hospital review at 6-12 months in clinic.
- A repeat MRI at 12 months and consideration of a further biopsy. If the PSA, scans and biopsy (if undertaken) remain stable then active surveillance will be continued.
- Thereafter to continue regular PSA blood tests indefinitely, 12 monthly clinic appointments and repeat assessment with scans and re-biopsy at two to four yearly intervals.
Q 4. What are the triggers for re-investigation or active treatment?
A. Any of these will trigger a revaluation or prompt a change in management strategy:
- Evidence of a significant rise in the PSA (typically three consecutive PSA rises)
- Any change in MRI scans and/or examination findings
- Patient preference for change
- Increase in tumour volume on repeat biopsies
Q 5. Are there any risks with active surveillance?
A. Changes to your cancer: There is a chance that your cancer could grow – but the tests used to monitor your cancer aim to find any changes early enough to start treatment. The monitoring plan described above is designed to be as rigorous and robust as possible to detect early any potential change in the cancer. There is always a small chance that changes may be missed.
Changes to your health: There is a chance that your general health could change, which would make some treatment (particularly surgery) unsuitable for you, if the cancer did grow. However, there are many very effective options to treat prostate cancer.
Concerns about active surveillance (psychological impact): Active surveillance isn’t for everyone. You might find it difficult not to have any treatment for prostate cancer, and worry that it will change or spread. You do not have to stay on active surveillance if you do not want to.
Side effects from repeat biopsies of the prostate: On an active surveillance programme you will require repeat prostate biopsies as part of the monitoring. Prostate biopsies do however have a small risk of infection and bleeding and this risk will apply for each biopsy episode though all steps will be taken to minimise this risk.
Q 6. What are the advantages of active surveillance?
- As you won’t have any treatment while on active surveillance, you will avoid the side effects.
- Active surveillance doesn’t interfere with your everyday life as much as treatment might do.
- If tests show that your cancer is growing, there are treatments available that can still cure it.
Q 7. What are the disadvantages of active surveillance?
- You might need to have more prostate biopsies which can cause side effects, and which some men find uncomfortable and painful.
- Your general health could change, which might make some treatments unsuitable for you if you need them.
- Your cancer might grow more quickly than expected, but the chance that this will happen is small.
- Not having treatment can cause high levels of worry in patients about the possibility of their cancer growing.
Q 8. What to expect after deciding to have active surveillance?
- You do not need to change your lifestyle or activities.
- Your first appointment will be in three to four months from the diagnosis.
- You need to have your PSA done prior to this appointment.
- You may have an MRI scan before the first appointment or the MRI is sometimes recommended after the appointment.
- At your first appointment, the MRI results along with repeat biopsy and type of biopsy and as well as follow up plans will be discussed.
- You can also come off surveillance and have active treatment at any point if you are worried.
Q 9. What are the alternatives to active surveillance?
- Brachytherapy (a form of internal radiotherapy which involves implanting ‘seeds’ of radioactive material directly into your prostate gland under a general or spinal anaesthetic)
- External beam radiotherapy (beams of radiation to destroy the cancer cells)
- Radical prostatectomy (removal of the entire prostate gland)
