The word on the page
A man sits across from me with his biopsy report folded in his hand. He has read it many times. He has underlined the word carcinoma. His wife has a notebook open to a clean page. They have come to hear what we are going to do about the cancer, and they expect the answer to involve an operating room.
The people in these essays are composites, drawn from many conversations over the years, with the details changed. The conversation itself repeats almost word for word, which is why I wanted to write it down.
When the report shows a small amount of Grade Group 1 cancer, what pathologists used to call Gleason 6, my first job is to slow the room down. I tell him the diagnosis is real. I also tell him that this kind of prostate cancer behaves very differently from the cancer that may have taken a friend or a relative. It tends to grow slowly. It rarely spreads. Many men live with cancers like this for the rest of their lives without being harmed by them.
Then I tell him what the guidelines say, because I want him to know this is the standard of care and something more than my personal taste. The American Urological Association recommends active surveillance as the preferred management for low-risk prostate cancer, and it gives that recommendation its strongest rating. The NCCN guidelines, written by a different panel, also describe surveillance as preferred for most men in the low-risk group. When two careful committees reach the same place, I take it seriously, and I ask my patients to do the same.
What watching actually involves
The name is part of the problem. Watching sounds passive. Patients hear it as being sent home and told to hope. Active surveillance is a schedule of work. It has blood tests, an MRI, and repeat biopsies, and it has a plan for what we will do if any of them change.
The AUA guideline says that men on surveillance should be monitored with serial PSA values and repeat prostate biopsy. It also says that MRI should be used to sharpen the picture and should not replace periodic biopsy. I explain that sentence carefully, because it surprises people. An MRI is a good map. Some cancers still do not show on it. The biopsy is how we check the map against the ground.
Before we commit to surveillance, I usually want a confirmation step. That means an MRI if one has not been done, and often a confirmatory biopsy early on to make sure the first one did not miss something larger. I perform these biopsies through the skin behind the scrotum, guided by the MRI, and I try to make each one count. A man on surveillance may have several over the years. He deserves to have each one done carefully and explained afterward in plain words.
Who it suits
Surveillance fits best for a man with Grade Group 1 cancer, a PSA that is not climbing quickly, and an MRI that does not show a large or worrying area. It also fits a man who can live with some uncertainty and who will come back for his tests. That second part matters as much as the pathology.
For favorable intermediate-risk cancer, which usually means a small amount of Grade Group 2, the AUA guideline asks me to discuss surveillance, radiation, and surgery. That is a real conversation with real tradeoffs. Some men in this group do well on surveillance. Others prefer treatment, and I think that is a reasonable choice for them. I try not to lean in either direction until I understand what the man in front of me fears most.
There are men I steer away from surveillance. Sometimes the MRI shows an area the biopsy may have undersampled. Sometimes the details of the pathology make me less certain the cancer is as quiet as it looks. Sometimes a man tells me plainly that he will not sleep well for the next ten years. For him, the anxiety itself is a cost, and I count it.
When the plan changes
Every man on surveillance asks me the same question at some point. How will we know when it is time? The answer is that we agree on the triggers before we start. If a biopsy shows a higher grade, if the amount of cancer grows meaningfully, or if the MRI shows a new area that a biopsy confirms, we talk about treatment. A slow drift in PSA by itself rarely decides anything. It makes me look harder.
Moving to treatment is the program doing its job. I say this deliberately, because men often feel they have failed surveillance. They did nothing wrong. We watched the cancer closely enough to see it change, and we found the change while it was still curable. That was the reason for watching in the first place.
Leaving surveillance does not commit anyone to a single treatment. A man who moves to treatment has the same options as any man with that grade of cancer, and we choose among them together.
What surveillance asks of a person
The AUA guideline reminds clinicians that every prostate cancer treatment carries risk to urinary, sexual, and bowel function, and that those risks have to be weighed against the risk of the cancer, the patient's life expectancy, his other health conditions, and his own preferences. I find that sentence useful in clinic. It reminds me that an operation which removes a harmless cancer has still cost the man something. The surgery may go exactly as planned. He may still leak when he coughs for months, and he may lose erections he valued. For a cancer that was unlikely ever to hurt him, that is a trade I do not want to make on his behalf.
Surveillance has costs too. There is the needle, the MRI tube, and the waiting room before results. There is the low hum of knowing. Some men carry this easily. Some find it heavy. I ask about it at every visit, because the right plan for a man who sleeps well is different from the right plan for a man who checks his patient portal every morning.
I am a surgeon, and I believe in what a good prostatectomy can do for the right man. Part of doing this job well is telling a man, honestly and with some confidence, that he does not need an operation yet. Most of the men who hear that from me leave the room lighter than they came in. Some of them will need treatment one day. When that day comes, we will have watched closely enough to know.
Reviewed by the author ·
This is one surgeon's perspective, written for general education. It is not advice for any individual. Decisions about your care belong in a conversation with your own doctors.