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Active surveillance and watchful waiting

Active surveillance and watchful waiting are the most common treatment options recommended when you are first diagnosed with prostate cancer.

However, if you’re not satisfied and want to take action on your prostate cancer, talk to us for a second opinion.

At The Focal Therapy Clinic, our expert team of clinical specialists are experienced with all current prostate cancer treatments. They can help you understand all your options and make a decision that you can be confident in.

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Mr Alan Doherty: How long should I stay on the Active Surveillance protocol?
01:14
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Mr. Alan Doherty (Consultant Urologist, The Focal Therapy Clinic): Active surveillance may not always make senseif the cancer is visible on MRI, it can be targeted with focal therapy instead of waiting for it to progress. Treating early with a minimally invasive approach may help avoid more aggressive treatments later. Mr Alan Doherty - https://www.thefocaltherapyclinic.co.uk/about-us/our-consultants/mr-alan-doherty/ active surveillance - https://www.thefocaltherapyclinic.co.uk/living-with-prostate-cancer/treatment-options/active-surveillance/ 00:01 Introduction 00:03 Why Patients Seek a Second Opinion 00:04 Reassessing Active Surveillance Decisions 00:08 Key Question: Why Was Cancer Found if It Doesnt Need Treatment? 00:15 Only Diagnosing MRI-Visible Cancers in His Practice 00:18 If Cancer Is Visible, It Can Be Targeted (HIFU, NanoKnife) 00:25 If Treatable, Why Wait? 00:27 What Are We Waiting for in Active Surveillance? 00:33 PSA Doubling: Who Decides When Its Dangerous? 00:38 Waiting for Gleason Score to Increase (Requires Another Biopsy) 00:43 How Do We Know When Cancer Is About to Spread? 00:47 A Different View on Surveillance 00:57 If Cancer Is NOT Visible on MRI, Waiting May Be Reasonable 01:01 Visible Cancer Suggests Clinical Significance 01:05 Early Focal Therapy Makes More Sense Than Waiting

TRANSCRIPT
Mr. Alan Doherty: Many patients come to me for a **second opinion** after being placed on **active surveillance**. When I assess their case, I ask: ### **Why was the cancer found if it doesn't need treatment?** - In my practice, I only diagnose cancers that are **visible on an MRI scan**. - If cancer is **visible**, that means we can **target it with focal therapy** (e.g., HIFU or NanoKnife). - If it can be **targeted and treated**, **why wait?** ### **What are we waiting for in active surveillance?** - **PSA levels to double?** Who determines when the level is dangerous? - **Gleason score to increase?** That requires another biopsy—what score makes treatment necessary? - **How do we know when cancer is about to spread?** ### **A Different Approach to Surveillance** If a cancer is **not visible on MRI**, then waiting **may be reasonable**—because that likely means the cancer is **clinically insignificant**. But if the cancer **is visible**, **why delay treatment** and take the risk of progression? In my view, **early focal therapy makes more sense** than waiting for signs of worsening disease.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
Mr Tim Dudderidge Should I consider focal therapy if I'm on active surveillance
01:41
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Mr. Tim Dudderidge (Consultant Urologist, The Focal Therapy Clinic): Active surveillance is for low-risk prostate cancer, but if monitoring causes anxiety, focal therapy may be an option for targeted treatment while avoiding unnecessary interventions. This approach balances effective cancer control with quality of life.

TRANSCRIPT
Mr. Tim Dudderidge: If you're on **active surveillance**, it typically means your prostate cancer is **low-risk or low-level intermediate-risk**. This suggests that: - It is **not an immediate threat**. - It **may or may not** become a problem later in life. - **Regular monitoring** will help detect any concerning changes. For many men, **active surveillance is reassuring**, knowing that early intervention will be taken if needed. However, for some, the idea of **watching and waiting** can feel like having a **ticking time bomb** inside them. **My role is to provide reassurance** by explaining: - The **steps we take to monitor the situation**. - The importance of **high-quality MRI scans and PSA tests**. - That **early intervention will be possible** if concerning changes develop. However, for some men, this reassurance **isn’t enough**. In such cases, **focal therapy** may be a good option—particularly if there is a **visible lesion of concern**. This approach: - Provides **a low-risk treatment**. - **Eliminates lingering anxiety** over possible progression. - Reduces the **risk of needing more aggressive treatment later**. At the same time, we want to **avoid overtreating men** with **trivial levels of disease**. Part of my job is to **help you determine whether treatment is truly necessary** or if **high-quality monitoring** remains the best approach for now. In some cases, **focal therapy may be appropriate in a few years** rather than immediately. Second opinions at **The Focal Therapy Clinic** help provide **clarity and reassurance** so that each patient can make an informed decision.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
Mr Marc Laniado Focal Therapy addresses mental health issues after a prostate cancer diagnosis
00:51
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Mr. Marc Laniado (Consultant Urologist, The Focal Therapy Clinic): Active surveillance is recommended for slow-growing prostate cancer, but if anxiety over PSA tests disrupts your life, focal therapy may be a better option. It effectively treats cancer with fewer side effects while preserving quality of life.

TRANSCRIPT
Mr. Marc Laniado: You’ve been offered **active surveillance** because your cancer is **considered slow-growing**, and this aligns with **NICE guidelines**. However, active surveillance **isn’t the right choice for everyone**. It may not be right for you if: - You find yourself **waking up anxious** about your diagnosis. - Every **PSA test causes extreme stress**. - The thought of repeated **doctor visits is affecting your quality of life**. If active surveillance is **causing significant anxiety**, **focal therapy** may be an alternative. - **Focal therapy can treat the cancer with fewer side effects** than radical treatments. - It can **eliminate the cancer**, allowing you to move forward **without constant worry**. For some men, **having treatment rather than watching and waiting** provides **peace of mind and a better quality of life**.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
Mr Alan Doherty I've been put on active surveillance I hate the idea of having cancer
01:15
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Mr. Alan Doherty (Consultant Urologist, The Focal Therapy Clinic): Active surveillance is considered safe, but if cancer is visible on an MRI and can be treated with minimal side effects, why wait? Cancer only worsens over time, so early treatment with focal therapy may be a better option to prevent progression while preserving quality of life.

TRANSCRIPT
Mr. Alan Doherty: **Active surveillance** has become a popular option because studies show that **starting with surveillance does not negatively impact survival outcomes** compared to immediate **surgery or focal therapy**. However, I believe it's important to ask: - **If you can see a cancerous lesion and treat it with minimal side effects, why wouldn't you?** - **Prostate cancer only worsens over time**—the speed of progression varies, but it will always advance. - **If we can detect it early, we can target and destroy it before it grows.** If someone chooses **active surveillance**, they must consider: 1. **Why did they choose early detection in the first place?** If they didn’t want treatment, why undergo screening? 2. **We now have the technology to treat early-stage cancers effectively** with minimal side effects, so delaying treatment may not be the best option. I believe **active surveillance should only exist if we cannot see the cancer clearly**—because if it’s visible and treatable, **why wait?**

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
Mr Alan Doherty If I'm on active surveillance, how likely is it that I'll need treatment
00:44
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Mr. Alan Doherty (Consultant Urologist, The Focal Therapy Clinic): Active surveillance is a common choice, but studies like ProtecT show that 2025% opt for treatment within 2 years due to PSA changes, and 50% receive treatment within 10 years. Understanding the likelihood of progression can help men make informed decisions about early intervention.

TRANSCRIPT
Mr. Alan Doherty: People who choose **active surveillance** often base their decision on **large studies**, including the **ProtecT trial**, which provides long-term data on outcomes. Findings from ProtecT show that: - **20–25% of men** on active surveillance **opt for treatment within two years**, often due to **changes in PSA levels** or psychological distress—even when treatment isn’t clinically recommended. - **50% of men** who initially choose active surveillance end up receiving **some form of treatment within 10 years**. These numbers highlight the **emotional and clinical challenges** of active surveillance and the importance of **ongoing monitoring and decision-making support**.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
Dr Christos Mikropoulos How often am I tested once I'm put on active surveillance
00:26
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Dr. Christos Mikropoulos (Oncologist, The Focal Therapy Clinic): Active surveillance follows European guidelines, involving PSA tests every 36 months, annual MRI scans, and biopsies if MRI changes are detected. This structured approach ensures close monitoring while delaying or avoiding unnecessary treatment.

TRANSCRIPT
Dr. Christos Mikropoulos: **Active surveillance** is typically based on **European Association of Urology (EAU) guidelines** in the UK. The standard monitoring approach includes: - **PSA blood tests** every **3 to 6 months** - **MRI scans** once a year - **Prostate biopsies** if MRI scans show any changes If an MRI detects **suspicious changes**, a **repeat biopsy** may be required to reassess the cancer status and determine if treatment is needed.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
Dr Christos Mikropoulos Will I need another biopsy while on Active Surveillance
00:14
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Dr. Christos Mikropoulos (Oncologist, The Focal Therapy Clinic): Patients on active surveillance will likely need another biopsy within two years to monitor any changes in their prostate cancer status. Regular PSA tests and MRI scans help track progression and guide treatment decisions when necessary.

TRANSCRIPT
Dr. Christos Mikropoulos: Being on **active surveillance** means that it is **very likely** you will need **another biopsy within the next two years**. This follow-up biopsy helps monitor any changes in your prostate cancer and ensures that treatment decisions remain based on the **most up-to-date information**.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
Mr Marc Laniado If I'm on active surveillance or watchful waiting, how likely is it that I'll nee
01:47
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Mr. Marc Laniado (Consultant Urologist, The Focal Therapy Clinic): Active surveillance is an option, but delaying treatment may increase risks. Early focal therapy treats a smaller area, preserves healthy tissue, and reduces the likelihood of progression to more invasive treatments like surgery or radiotherapy.

TRANSCRIPT
Mr Marc Laniado: If you’ve been told you can have active surveillance, that is certainly an option. However, studies show that about one-third to two-thirds of men on active surveillance eventually require treatment. When considering active surveillance, think about the impact of treating cancer early versus delaying treatment. If we deliver focal therapy early, we can target a smaller part of the prostate with a minimal margin. This allows for more reliable cancer eradication while preserving almost all of the healthy prostate tissue. If the cancer progresses and becomes larger, more of the prostate will need treatment, reducing the amount of healthy tissue that can be preserved. This also increases the likelihood of side effects. In some cases, the cancer may progress to a point where focal therapy is no longer an option, requiring whole-gland treatments like surgery or radiotherapy instead. While small cancers can often be monitored, active surveillance involves frequent tests and MRI scans. Some men are comfortable with this, but others find the uncertainty and anxiety difficult to manage. The uncertainty surrounding which cancers will progress can impact quality of life, causing stress, depression, and other concerns. One advantage of early focal therapy is the reassurance that the cancer has been treated, reducing the risk of progression and the need for more aggressive treatments later on.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
What is active surveillance for prostate cancer?
00:27
Playlist
Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Dr. Christos Mikropoulos (Oncologist, The Focal Therapy Clinic): Active surveillance manages low-risk prostate cancer without immediate treatment, using regular MRI scans, blood tests, and biopsies to monitor for any changes. This approach helps avoid unnecessary interventions while ensuring timely treatment if needed.

TRANSCRIPT
Dr. Christos Mikropoulos: ### **What Is Active Surveillance?** **Active surveillance** is a **structured protocol** for managing **low-risk prostate cancer** without offering **immediate treatment**. Instead of treating the cancer right away, we: - **Closely monitor the disease** for any changes. - Offer treatment **only if the cancer shows signs of progression**. ### **How Is Active Surveillance Managed?** Patients undergo: - **Regular MRI scans** to track changes in the prostate. - **PSA blood tests** to monitor tumor activity. - **Prostate biopsies when needed** to check for increased aggressiveness. ### **Why Choose Active Surveillance?** - It helps men **avoid unnecessary treatment and side effects**. - It ensures **timely intervention if the cancer becomes more aggressive**. - It is an effective option for **men with slow-growing prostate cancer** who prefer to delay or avoid treatment. With **careful monitoring**, active surveillance allows men to **maintain their quality of life** while ensuring that treatment is available **if and when it becomes necessary**.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
Downsides of active surveillance for prostate cancer
00:58
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Mr. Marc Laniado (Consultant Urologist, The Focal Therapy Clinic): Active surveillance requires frequent PSA tests, MRIs, and biopsies, which can have side effects and cause anxiety. Focal therapy removes the tumor, reducing the need for repeated biopsies while maintaining excellent cancer control and preserving quality of life.

TRANSCRIPT
Mr. Marc Laniado: ### **The Downsides of Active Surveillance** One of the biggest drawbacks of **active surveillance** is the need for: - **Regular PSA tests** - **Frequent MRI scans** - **Repeated prostate biopsies**, which can cause discomfort and potential side effects In some places, **repeated biopsies are required by protocol**, meaning that **all patients must undergo them**, even if their MRI and PSA results remain stable. This process can **cause complications and increase anxiety** for some men. ### **The Advantage of Focal Therapy** - **Focal therapy removes the tumor**, eliminating the need for ongoing surveillance. - **After treatment, follow-up is primarily done with MRI scans and PSA tests**. - If **MRI quality is high and PSA levels remain low**, **no further biopsies are needed**. ### **What This Means for Patients** - You get the **benefit of having the cancer treated** rather than monitored. - You gain **peace of mind** knowing that action has been taken. - **In most cases, you can continue life without ongoing concerns** about progression or repeated invasive testing. For men who are **uncomfortable with the uncertainty and repeated biopsies associated with active surveillance**, **focal therapy provides an alternative that offers both cancer control and quality of life benefits**.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.
Active surveillance & watchful waiting for prostate cancer: when will I need more?
00:59
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Active Surveillance for Early Stage Prostate Cancer
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SUMMARY
Mr. Marc Laniado, Mr. Alan Doherty, Dr. Christos Mikropoulos (The Focal Therapy Clinic): Active surveillance delays treatment, but most men eventually need intervention. Studies show that 2025% opt for treatment within 2 years due to PSA anxiety, and many require treatment within a few years. Considering early focal therapy can help maintain quality of life while effectively managing cancer.

TRANSCRIPT
Mr. Marc Laniado, Mr. Alan Doherty, Dr. Christos Mikropoulos: ### **What Does Active Surveillance Mean?** If you have been placed on **active surveillance**, this is a **formal approach to monitoring your prostate cancer** instead of immediately treating it. ### **What Do Studies Show?** - **One-third to two-thirds of men eventually require treatment**. - The **ProtecT trial** found that within **two years**, **20–25% of men opted for treatment** due to **anxiety over PSA changes**, even when treatment was not clinically required. ### **Should You Delay or Start Treatment Early?** - **Prostate cancer changes over time**, and **most men will eventually need treatment**. - The key question to consider is: - **Is it better to treat the cancer now, while it’s manageable?** - **Or should you wait, knowing that intervention will likely be needed later?** Since **most men on active surveillance will require treatment at some stage**, it’s important to discuss whether **early focal therapy** might be a better option to maintain **both cancer control and quality of life**.

This content is not intended to be a substitute for professional medical advice, diagnosis, or treatment. Read more.

How it works

If your cancer is very early, or growing very slowly, your doctor might suggest active surveillance or watchful waiting.

Active surveillance

Active surveillance involves regular scans and tests to monitor the progression of your cancer, if it’s caught early or looks like it’s growing so slowly you might not need treatment. You will have:

  • Regular multiparametric MRIs (mpMRIs), also known as prostate MRIs, every 12-18 months
  • PSA blood tests every 3-4 months

Previously, if you were on active surveillance, you would also have regular prostate biopsies. However, advances in MRI technology have reduced the need for this. However, if your cancer changes or pgoresses, you might need a biopsy to diagnose it for definite.

Watchful waiting

Watchful waiting also involves monitoring your cancer, but only using PSA tests and regular GP visits to check your symptoms. You’ll be recommended watchful waiting if:

  • You are older and don’t have any symptoms
  • You have another medical condition that might make prostate cancer treatment difficult
  • You would rather avoid any treatment and its side effects

Suitability

You are most likely to be recommended active surveillance if you have early, or localised, prostate cancer or locally advanced cancer, and you’re older and overall less fit and healthy.

However, if you’re not happy with the risks posed by your prostate cancer, including the anxiety of having a cancer diagnosis, other treatment options could be better for you.

Success rates

Active surveillance has been shown to be safe and effective in reducing treatment for people with early-stage prostate cancer. You have roughly the same chance of living for 10 years after your diagnosis as you do if you choose to have surgery or radiotherapy.

Side effects

If your cancer changes or you experience new side effects, you might need additional tests, such as biopsy. You may also need more radical treatment than focal therapy.

For some people, their cancer diagnosis can cause stress and anxiety, which impacts their overall health. You might decide that you’d prefer to risk an early treatment intervention than your cancer growing whilst you aren’t having treatment.

If you’re on active surveillance or watchful waiting and would like to explore your other treatment options:
contact us today

Any questions?

If you’ve got any questions about your prostate cancer diagnosis or want to know more about HIFU treatment or NanoKnife treatment, don’t hesitate to get in touch with our friendly, knowledgeable team.

0207 036 8870

info@thefocaltherapyclinic.co.uk

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    Learn more about diagnosis and active surveillance

    Frequently asked questions

    Why should I consider active surveillance for prostate cancer?
    Active surveillance is recommended for men with low-risk or low-level intermediate-risk prostate cancer. As Mr. Tim Dudderidge (Consultant Urologist, The Focal Therapy Clinic) explains:

    “If you’re on active surveillance, it typically means your prostate cancer is low-risk or low-level intermediate-risk. This suggests that it is not an immediate threat, it may or may not become a problem later in life, and regular monitoring will help detect any concerning changes.”

    Active surveillance allows you to avoid immediate treatment and its potential side effects, while ensuring early intervention is possible if the cancer shows signs of progression. It’s particularly suitable for men with early or localised prostate cancer, Gleason score ≤6, PSA <10–15 ng/ml, and low-risk disease characteristics.

    For many men, active surveillance is reassuring, knowing that high-quality monitoring with MRI scans and PSA tests will detect any concerning changes early.

    Why should I stay on active surveillance if my cancer is visible on MRI?
    This is an important question that many patients ask when seeking second opinions. Mr. Alan Doherty (Consultant Urological Surgeon, The Focal Therapy Clinic) addresses this concern:

    “Many patients come to me for a second opinion after being placed on active surveillance. When I assess their case, I ask: Why was the cancer found if it doesn’t need treatment? In my practice, I only diagnose cancers that are visible on an MRI scan. If cancer is visible, that means we can target it with focal therapy (e.g., HIFU or NanoKnife). If it can be targeted and treated, why wait?”

    Mr. Doherty explains that if cancer is not visible on MRI, active surveillance may be reasonable because the cancer is likely clinically insignificant. However, if the cancer is visible on MRI, early focal therapy may be a better option than waiting for signs of progression.

    Active surveillance remains a valid choice, but some men prefer to treat visible lesions early with minimally invasive focal therapy rather than monitor a known cancer. This is a personal decision that should be made with your consultant after considering your cancer characteristics, anxiety level about living with untreated cancer, preference for early intervention vs monitoring, and the availability of minimally invasive treatment options.

    What proportion of men on active surveillance eventually need treatment?
    Understanding progression rates is important when choosing active surveillance. Mr. Marc Laniado (Consultant Urological Surgeon, The Focal Therapy Clinic) provides clarity on this:

    “If you’ve been told you can have active surveillance, that is certainly an option. However, studies show that about one-third to two-thirds of men on active surveillance eventually require treatment.”

    Mr. Laniado further explains:

    “When considering active surveillance, think about the impact of treating cancer early versus delaying treatment. If we deliver focal therapy early, we can target a smaller part of the prostate with a minimal margin. This allows for more reliable cancer eradication while preserving almost all of the healthy prostate tissue. If the cancer progresses and becomes larger, more of the prostate will need treatment, reducing the amount of healthy tissue that can be preserved.”

    • 33–66% of men on active surveillance eventually require treatment.
    • 20–25% choose treatment within 2 years due to anxiety over PSA tests and ongoing monitoring.
    • Early focal therapy can treat a smaller area, preserving more healthy tissue.
    • Delayed treatment may require more extensive intervention if cancer progresses.

    The decision between active surveillance and early focal therapy should consider your cancer characteristics, personal anxiety levels, and quality of life preferences.

    What tests and procedures are involved in the active surveillance protocol?
    Active surveillance follows a structured monitoring protocol based on European Association of Urology (EAU) guidelines. Dr. Christos Mikropoulos (Consultant Clinical Oncologist, The Focal Therapy Clinic) explains:

    “Active surveillance is typically based on European Association of Urology (EAU) guidelines in the UK. The standard monitoring approach includes PSA blood tests every 3 to 6 months, MRI scans once a year, and prostate biopsies if MRI scans show any changes.”

    • Regular PSA Tests: Every 3–6 months to monitor for significant increases indicating possible progression.
    • Annual MRI Scans: Multiparametric MRI (mpMRI) every 12–18 months to track lesion changes or identify new areas.
    • Biopsies When Needed: Required if MRI shows suspicious changes to assess Gleason score increases.

    Dr. Mikropoulos notes: “Being on active surveillance means that it is very likely you will need another biopsy within the next two years. This follow-up biopsy helps monitor any changes in your prostate cancer and ensures that treatment decisions remain based on the most up-to-date information.”

    Treatment is recommended if monitoring reveals significant PSA rise, Gleason score increase, MRI changes, or if patient preference shifts due to anxiety or quality of life. High-quality MRI scans and experienced radiologists are essential for safe monitoring.

    How often will I be tested once I’m put on active surveillance?
    Active surveillance requires regular monitoring to ensure early detection of any cancer progression. Dr. Christos Mikropoulos (Consultant Clinical Oncologist) outlines the standard schedule:

    “Active surveillance is typically based on European Association of Urology (EAU) guidelines in the UK. The standard monitoring approach includes PSA blood tests every 3 to 6 months, MRI scans once a year, and prostate biopsies if MRI scans show any changes.”

    • PSA blood tests every 3–6 months
    • MRI scans annually (every 12–18 months)
    • Biopsies when MRI shows changes, typically within first 2 years

    This frequent testing schedule ensures any concerning changes are caught early, allowing for timely intervention. However, some men find the ongoing tests and appointments stressful, which is worth considering when choosing between active surveillance and early focal therapy.

    Will I need another biopsy while on active surveillance?
    Yes, repeat biopsies are very likely during active surveillance. Dr. Christos Mikropoulos (Consultant Clinical Oncologist) explains:

    “Being on active surveillance means that it is very likely you will need another biopsy within the next two years. This follow-up biopsy helps monitor any changes in your prostate cancer and ensures that treatment decisions remain based on the most up-to-date information.”

    Biopsies are typically required when MRI scans show suspicious changes, PSA levels rise significantly, or when confirmatory biopsies are due.

    Mr. Marc Laniado (Consultant Urologist) notes:

    “One of the biggest drawbacks of active surveillance is the need for regular PSA tests, frequent MRI scans, and repeated prostate biopsies, which can cause discomfort and potential side effects. In some places, repeated biopsies are required by protocol, meaning that all patients must undergo them, even if their MRI and PSA results remain stable.”

    Some men find repeated biopsies uncomfortable or anxiety-provoking, which may influence their decision between ongoing active surveillance and early focal therapy.

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