Most prostate cancer is slow. A large share of what screening detects would never have caused a symptom, shortened a life, or been discovered at all had the man not been tested. For decades that disease was treated anyway, with surgery or radiation, and the men who received that treatment paid for it in continence and sexual function without gaining anything.
Active surveillance is the response to that problem. It means the cancer is diagnosed, characterised, and then monitored on a defined schedule, with treatment held in reserve for the minority in whom the disease shows signs of becoming consequential. The evidence supporting it is now long-term: in the large randomised comparison of surgery, radiotherapy and monitoring for localised disease, prostate cancer mortality at fifteen years was low and did not differ significantly between the groups, although men on monitoring were more likely to have their disease progress or spread. The interpretation that has held up is that for genuinely low-risk disease, deferring treatment does not cost lives, while treating everyone certainly costs function.
Who it suits
Grade Group 1 disease — Gleason 3+3 — is the clearest case, and for many men it is now considered the preferred management rather than one option among several. Grade Group 2, where a pattern 4 component is present, is the genuinely debated territory: some of these men do well on surveillance, particularly where the pattern 4 proportion is small, the volume is low and the MRI is unremarkable, and others are better treated. Higher grades are generally not surveillance candidates.
Beyond grade, the decision takes in PSA density, how many cores are involved, what the MRI shows, family history, genetic findings such as BRCA2, your age and general health, and — this matters more than clinicians sometimes admit — how you personally live with the knowledge that an untreated cancer is present. A man who will be unable to sleep is not a good surveillance candidate however favourable his numbers, and saying so is not a failure of nerve.
What surveillance is not
It is not watchful waiting, which means no monitoring and treatment only for symptoms, and is appropriate for men whose life expectancy is short enough that the cancer is unlikely to matter. Surveillance is active: it has appointments, tests and a trigger for changing course.
The schedule
Typical monitoring involves PSA every six months, a clinical review at the same interval, an MRI at intervals of one to two years, and a confirmatory biopsy within the first year or two followed by repeat biopsies at longer intervals. The confirmatory biopsy matters: a proportion of men turn out to have higher-grade disease that the original sampling missed, and finding that early is the point of doing it.
MRI has reduced how often biopsies are needed but has not eliminated them. Imaging is good at showing change in a visible lesion and less good at excluding grade progression in disease it cannot see, so a schedule built only on MRI and PSA will miss some men. We discuss the biopsy interval individually rather than applying one protocol to everyone.
What triggers treatment
Not a single rising PSA — PSA fluctuates, and infection, an enlarging benign gland and laboratory variation all move it. The triggers that matter are an increase in grade on repeat biopsy, a substantial increase in the volume of disease, a new or growing lesion on MRI, and a sustained PSA trajectory that does not have a benign explanation. Patient preference is also a legitimate trigger: men who decide after two or three years that they would rather be treated are not making a mistake.
Roughly a third to a half of men on surveillance move to treatment within ten years. That is not a failure of the strategy. It is the strategy working as designed — deferring treatment for everyone and delivering it to the subset who turn out to need it, while the rest are spared entirely.
Living with it
The part least discussed is the psychological one. Carrying a diagnosis of untreated cancer is uncomfortable, particularly in the first year and particularly around each test. Most men settle as the results accumulate. What helps is knowing the schedule in advance, understanding what each test is looking for, and having a clear statement of what would change the plan, so that every PSA result is not experienced as a verdict. We write that plan down at the outset.
The other thing worth saying is that surveillance is a good moment to attend to everything else. Cardiovascular risk, weight, fitness and metabolic health will influence your next twenty years considerably more than a Grade Group 1 prostate cancer will, and our longevity programme and internal medicine service exist to make that argument concrete.
Questions patients ask
Is it safe to leave a cancer untreated?
For genuinely low-risk disease, the long-term evidence says yes — prostate cancer mortality in monitored men was low and not significantly different from treated men at fifteen years, though progression and spread were more common. The safety depends entirely on the monitoring actually happening, which is why the schedule matters.
How often will I need another biopsy?
Usually a confirmatory biopsy within the first year or two, then repeats at intervals of two to three years, adjusted by what the MRI and PSA are doing. MRI has reduced the frequency but has not replaced biopsy, because imaging is better at tracking a visible lesion than at excluding grade change it cannot see.
What if my PSA goes up?
A single rise is common and usually not significant. PSA moves with infection, with benign enlargement and with laboratory variation. What prompts action is a sustained trajectory without a benign explanation, considered alongside imaging and biopsy rather than alone.
Can I switch to treatment later without having lost the chance to cure it?
That is the central premise, and for appropriately selected men the evidence supports it — delayed treatment after progression on surveillance has outcomes comparable to immediate treatment. It depends on selection and on monitoring being adhered to, which is why men who cannot commit to the schedule are better treated up front.
Does diet or exercise change anything?
There is no diet that reliably alters the course of prostate cancer, and claims otherwise should be treated sceptically. Cardiovascular fitness, weight and metabolic health do strongly affect your overall outlook, and for a man with low-risk prostate cancer they are likely to matter more than the cancer.
Make an appointment
Manhattan (212) 991-9991 · Forest Hills (718) 360-9550 · same-week visits and most major insurance accepted.