Not every prostate cancer needs treatment right away

Hearing the words “you have prostate cancer” can be scary. For many men, the first instinct is to treat it as quickly as possible. But prostate cancers vary widely, and the best next step depends on the cancer’s risk features, the patient’s overall health, and what matters most to him.

About one in eight men will be diagnosed with prostate cancer. Yet immediate treatment can sometimes be safely delayed — and some men may never need it.

“Prostate cancer is not a single disease,” says Dr. Croix Fossum, a board-certified radiation oncologist with Sharp Community Medical Group and affiliated with Sharp Grossmont Hospital. “Some prostate cancers are aggressive, while others grow so slowly that they may never cause symptoms or shorten a patient’s life.”

For appropriately selected patients, immediate treatment may offer little benefit while causing side effects that affect quality of life.

When monitoring may be a better choice: Active surveillance vs. watchful waiting

Depending on the cancer’s risk, the patient’s health and life expectancy, and his goals, doctors may recommend active surveillance or watchful waiting.

Both defer treatment, but their goals and intensities differ.

“Active surveillance is a structured monitoring strategy for patients whose prostate cancer is unlikely to cause harm in the near future,” Dr. Fossum says.

“It typically includes regular prostate-specific antigen, or PSA, blood tests, clinical visits, periodic imaging, and repeat biopsy when appropriate. The goal is to preserve curative treatment as an option if meaningful progression appears.”

Watchful waiting, by contrast, is generally less intensive and has a different goal.

“It is most often used when a patient’s age or other medical conditions make it unlikely that curative prostate cancer treatment would extend his life,” Dr. Fossum says. “The focus is on maintaining quality of life and treating symptoms if they develop, rather than monitoring closely with the intent to offer curative treatment.”

Good candidates for monitoring

Active surveillance is most commonly recommended for men with early-stage, non-aggressive prostate cancer. It may also be appropriate for carefully selected men with favorable intermediate-risk disease. Patients should be healthy enough that curative treatment would remain appropriate if the cancer progresses.

Watchful waiting is generally more appropriate for older patients or those with significant medical conditions whose prostate cancer is unlikely to affect longevity. Age can be a factor, but overall health, life expectancy, patient priorities and the characteristics of the cancer all matter.

Some patients who are good candidates for active surveillance choose treatment because of anxiety about living with cancer, fear that it may spread, or concern about missing the opportunity for cure.

“It’s important to review the risk of progression, explain how surveillance identifies meaningful changes, and discuss the potential side effects of treatment,” Dr. Fossum says.

“I also make clear that this is a shared decision. Active surveillance may be the medically preferred option, but if living with untreated cancer causes persistent anxiety that substantially affects a patient’s quality of life, definitive treatment can still be reasonable after a careful discussion of its benefits and risks.”

Monitoring doesn't mean doing nothing

Dr. Fossum works closely with patients to decide whether monitoring fits both the cancer and what matters most to them.

Still, delaying treatment can feel like doing nothing.

“Active surveillance is not doing nothing,” he emphasizes. “It is an intentional management strategy with a defined monitoring plan and clear triggers for further evaluation or treatment.”

“The goal is to treat the right cancer at the right time, rather than treating every cancer immediately.”

Benefits of delaying treatment

Benefits include preserving quality of life and avoiding side effects of surgery or radiation therapy, which may include urinary and bowel symptoms and erectile dysfunction.

Surveillance also allows the care team to learn more about the cancer’s behavior. Some men remain safely on surveillance for years and never need treatment. With appropriate follow-up, changes can often be identified while curative treatment remains an option.

Moving to treatment

Treatment may be recommended if testing suggests the cancer is becoming more aggressive or extensive, such as a higher grade on repeat biopsy, concerning MRI changes or more cancer found on biopsy.

Changes in PSA are also considered. PSA levels can fluctuate for reasons unrelated to cancer, so a rising PSA does not necessarily mean treatment is needed. Instead, it may prompt additional evaluation and is interpreted alongside imaging, biopsy findings and the patient’s overall clinical picture.

Patient preferences can also change.

The goal is not to avoid treatment at all costs, but to give it at the right time and for the right reasons. For appropriately selected patients, careful monitoring is an active, evidence-based path forward.

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