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  • A new study finds men with prostate cancer are increasingly choosing active surveillance instead of invasive treatment such as surgery or radiation.
  • With active surveillance, if tests show that the cancer is growing faster, men can consider treatment options.
  • During the study period active surveillance among low-risk patients increased from 16% to 60%.

Active surveillance involves closely monitoring prostate cancer using a combination of blood tests, rectal prostate exams, prostate biopsies and imaging tests.

If these tests show that the cancer is growing faster or spreading, men can consider treatment options such as surgery or radiation therapy.

Active surveillance is an option for men with low-risk prostate cancer and for some men with favorable intermediate-risk prostate cancer.

For example, a doctor may recommend active surveillance if the cancer is small and present only in the prostate, is expected to grow slowly and is not causing any symptoms.

“We are already seeing an increase in the proportion of men on active surveillance, perhaps not at the rate we would want, but the numbers are encouraging,” study author Dr. Bashir Al Hussein Al Awamlh, a second-year urologic oncology fellow at Vanderbilt University Medical Center in Nashville, told Healthline.

“Our job is to continue to advocate for surveillance as the preferred treatment option for low-risk cancer,” he said. “By reinforcing the safety and benefits of surveillance and directing equitable efforts toward the groups with less uptake, we hope numbers continue to climb.”

For the study, published April 3 in JAMA Internal Medicine, researchers examined data from 2010 to 2018 on over 105,000 men in the United States with prostate cancer.

The study included only men who underwent active surveillance or received treatment, rather than all men with prostate cancer.

Active surveillance among low-risk patients increased from 16% to 60% during that time, and from 8% to 22% for patients with favorable intermediate-risk prostate cancer.

Even with the increase in active surveillance during the study period, the percentage of low-risk patients choosing this option was lower than rates seen in other countries — for example, 74% in Sweden in 2014 and 67% in Australia in 2016.

However, the researchers pointed out that direct comparisons between countries are difficult because of differences in populations.

Dr. David Lee, a urologist and director of the Comprehensive Prostate Cancer Program at UCI Health in Orange County, Calif., who was not involved in the study, cautioned that increasing active surveillance rates should not be the end goal, in and of itself.

Instead, “finding the right fit for the individual patient should be the more precise target to hit,” he told Healthline.

In addition, “while I agree that active surveillance is likely not offered as often as it should be, this treatment option is not appropriate for all men with low-risk disease,” he said.

Active surveillance is not an easy thing for patients to do. It requires them to commit to having regular prostate-specific antigen (PSA) blood tests, and routine MRIs and prostate biopsies.

In addition, “the thought of having a cancer inside one’s body can be very anxiety provoking,” said Lee, “which can dissuade some men from active surveillance.”

While active surveillance rates rose overall in the United States from 2010 to 2018, the new study showed that some groups lagged behind.

Asian Americans and Pacific Islanders and Hispanic men, men with lower incomes, and men living in rural areas were less likely choose or be offered active surveillance, researchers found.

Al Hussein Al Awamlh said disparities such as this in cancer care is a well-recognized issue.

“Previous research has shown that certain groups lack access to adequate healthcare and are more subject to low health literacy,” he told Healthline. “Our study suggests that advocating for surveillance in these communities is important to limit these inequities.”

Dr. Peter Gann, a professor of pathology at the University of Illinois Chicago College of Medicine, who was not involved in the study, pointed out that in the new study, Black men had similar rates of active surveillance as whites.

This contrasts with some earlier research which found that Black men were less likely to accept active surveillance for prostate cancer than whites.

So why the difference?

Gann thinks it might be because the authors of the new study took into account patients’ income level, which reduced the differences in the rates seen between whites and Blacks.

Active surveillance is a relatively new treatment option for prostate cancer, one that requires patients to make a very complex decision, said Gann.

“We’re sort of saying, ‘Okay, you have cancer, but we’re just going to watch it.’ Psychologically, that’s a pretty heavy burden for anybody to carry,” he told Healthline.

To help decide if active surveillance is safe for a particular patient, doctors look at a number of factors, said study author Dr. Jonathan Shoag, a urologist at University Hospitals and an associate professor of urology at Case Western Reserve University School of Medicine in Cleveland.

These include a patient’s age and health, a clinical exam, prostate biopsies, imaging results and the PSA blood test.

“These metrics are imperfect, and there are a lot of efforts to better stratify patients’ risk using genomic tests, for instance,” Shoag told Healthline.

In addition, “data suggest many of these tests in practice actually bias away from watching cancers,” he said, “which is maybe not a good thing, and as such, many of us feel these [tests] are not ready for prime-time.”

Even tools designed to help patients make decisions about active surveillance can lead to health disparities.

In a study published in 2021 in the Journal of Clinical Oncology, Gann and his colleagues looked at the use of active surveillance among men who had tumor gene profiling.

Tumor gene profiling, or genomic profiling, is a tool that “provides significant new information to help us understand how aggressive your cancer is,” Gann said.

They found that men with low health literacy were seven times less likely to accept active surveillance after having tumor gene profiling, compared with those with high health literacy.

The study was carried out in a predominantly Black, urban patient population with substantial social disadvantage. Earlier studies using this tool were done in predominantly white populations.

Gann said research like this and the new JAMA Internal Medicine study points to the need for improved communication between physician and patient, so decisions about active surveillance are in the best interests of the patient.

For example, you don’t want physicians making assumptions about whether a patient would do well with active surveillance based on their education, income or other factors, he said.

“These studies open up a lot of questions about how these difficult decisions are made,” Gann said, “and how the characteristics of the individual doctor and patient can sometimes influence them.”