Active surveillance is becoming more popular as a treatment option for low-risk, low-grade (Gleason 3+3=6), possibly insignificant, prostate cancer.
The definition of 'insignificant prostate cancer' does, however, remain unclear and unproven. Nevertheless, it is clear that men, particularly with an age of >65 years, with low-risk, low-grade (Gleason 6 or less) prostate cancer, may not die from their disease, even if it is left untreated for long periods of time.
Active surveillance is not a passive process and really involves the close monitoring of tumours, to avoid the tumour going from curable to incurable during a defined period of time. This involves regular PSA readings, regular digital rectal examinations and periodic biopsies.
It is my policy to recommend a six-monthly PSA readings, a twelve-monthly digital rectal examination and a repeat biopsy between 12 and 18 months after the initial biopsy. Depending on the result of that, one either continues on this program or, if the tumour appears quiescent, or even undetectable, one can increase the period between biopsies to every 2 to 4 years, depending on the circumstances.
The active surveillance program is generally not continued if there is evidence of rapid rise of PSA, increase in size of tumour on biopsy, or increase in Gleason Score of the tumour on biopsy.
Trials that have looked at people who have adopted this policy, have shown that approximately 1/3 of patients will need treatment within five years of follow-up. Of those patients who did need treatment, the vast majority are still curable, even after a five-year delay, as long as there is close surveillance. It is believed that, based on careful selection of patients for active surveillance, <5% will become incurable if monitored carefully. Three papers (listed below) would serve as references for those interested in researching this further.