b) Active Surveillance


A significant number of patients diagnosed with low risk prostate cancer will never develop symptoms of the disease. This group typically includes men with Gleason 6 (3+3) disease that is not palpable and in whom the PSA is less than 10. If these men are followed up closely, those with progressive disease can be offered definitive treatment whereas those with indolent disease can be observed without the need for invasive therapy.


There are no randomised studies supporting active surveillance. However, there is strong evidence from observational studies:

  • The Toronto study observed over 400 men with active surveillance. There were offered repeat TRUS biopsy at 12 months and 3 monthly PSA; definitive therapy was instituted if the PSA doubling time was < 3 years or if repeat biopsy confirmed Gleason 7 disease.
    • In this group, the 10 year prostate cancer specific survival was 97%
    • 30% of patients required definitive therapy


The main benefit of avoiding therapy is quality of life for the patient. Treatment is associated with erectile dysfunction in most patients, and bladder or bowel effects depending on the treatment chosen.


The two main harms are:

  • Possibility of reduced cure with delayed treatment. Gleason 7 disease has consistently worse outcomes than Gleason 6.
  • Patient anxiety over untreated disease. This is particularly hard to quantify


Active surveillance should be discussed as an option with patients with Gleason 6, non-palpable, PSA < 10 disease. They should be advised of the potential benefits and risks but also that there is no randomised evidence to guide treatment.