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Active Surveillance: Monitoring Prostate Cancer Without Immediate Treatment

Not every prostate cancer needs immediate treatment. In carefully selected men, cancer can be safely monitored over time, delaying — or sometimes completely avoiding — surgery or radiotherapy.

Monitors the cancer closely with regular PSA testing
Uses MRI scans and repeat biopsies when needed
You remain under the care of a specialist team
Treatment remains available — and effective — if needed.
Confirmed by the 15-year UK ProtecT trial: cancer-specific mortality was comparable across active monitoring, surgery, and radiotherapy arms (Hamdy et al., NEJM 2023).

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Mr Alan Doherty: How long should I stay on the Active Surveillance protocol?

What is Active Surveillance?

Active surveillance is a clinically guided strategy for monitoring early-stage prostate cancer when immediate treatment is not necessary. Patients have regular PSA tests, MRI scans, and biopsies when indicated, allowing treatment to be started only if the disease shows signs of progression.

Low-risk prostate cancer — small tumours that are slow-growing and unlikely to cause harm soon.

Favourable intermediate-risk disease — where careful monitoring may be appropriate before considering treatment.<

Small, well-localised tumours that show no signs of aggression on MRI or biopsy.

Men who prioritise quality of life, wanting to delay or avoid the side effects of surgery, radiotherapy or hormone therapy.

Active Surveillance vs Watchful Waiting

When managing prostate cancer without immediate treatment, two terms you might hear are Active Surveillance and Watchful Waiting — and though they sound similar, they are clinically different strategies with distinct goals.

	Active Surveillance	Watchful Waiting
PSA Testing	Frequent PSA tests, exams, imaging, and biopsies to actively monitor cancer progression.	Monitoring is more symptom-driven with fewer structured tests.
Symptom Management	The goal is to detect changes early and treat with curative intent if needed.	Treatment focuses on managing symptoms should they arise.
Suitability for Recurrent Cancer	Suitable for newly diagnosed low-risk and favourable intermediate-risk localised prostate cancer (Gleason 6, or favourable Gleason 3+4=7; PSA <10-15 ng/mL; stage T1c-T2a).	Used when curative treatment is unlikely to be tolerated or beneficial — typically for men with limited life expectancy, significant comorbidities, or very advanced age (NICE NG131, 2021).
Approach to Monitoring	Monitoring follows a structured schedule agreed with clinicians.	Monitoring is less intensive and responds to symptom changes.
Cancer Stage	Typically offered to men with localised, slow-growing prostate cancer who are candidates for later curative treatment.	Often used for men with limited life expectancy or other health issues where curative treatment is unlikely to be beneficial.

Sources: NICE NG131 (2021); PRIAS protocol (European multicentre); EAU Prostate Cancer Guidelines 2024.

“Active surveillance is a structured, test‑guided monitoring strategy with the intention of curative intervention if the disease changes. Watchful waiting, by contrast, is a less intensive, symptom‑driven approach without the same focus on curative treatment.”

Dr Christos Mikropoulos, Oncologist

A consultation with a prostate cancer specialist is necessary to determine the best treatment choice.

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What Does Active Surveillance Involve?

Regular PSA Tests

Ongoing blood tests track prostate-specific antigen levels to detect any changes early.

Typically every 3-6 months for the first 2 years, then 6-monthly (PRIAS protocol; NICE NG131).

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Advanced MRI Scans

High-resolution imaging helps pinpoint areas of concern and guide any necessary intervention.

Multi-parametric MRI at intervals of 1-3 years, or sooner if PSA changes (NICE NG131).

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Targeted Biopsies

Performed only when indicated, biopsies confirm the presence or progression of cancer, keeping treatment decisions precise and focused.

Repeat MRI-guided biopsy at year 1, then approximately every 3-4 years — or sooner if imaging or PSA suggests progression.

Ongoing Clinical Review

Regular consultations with experienced specialists ensure that your monitoring plan is tailored, structured, and evidence-based.

Regular consultations with a focal therapy specialist, with a defined pathway to focal therapy, surgery or radiotherapy if and when intervention becomes appropriate.

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Is Active Surveillance Safe?

It's natural to worry about monitoring prostate cancer without immediate treatment is a common worry. The evidence base is reassuring. Large studies show that, for many men with low-risk or favourable disease, active surveillance is a safe, effective approach.

Many men remain treatment-free for years — Around half of men on active surveillance remain treatment-free 10 years after diagnosis (PRIAS registry; ProtecT trial 15-year follow-up, Hamdy et al., NEJM 2023). Critically, prostate cancer mortality at 15 years in the UK ProtecT trial was low across all three arms — 3.1% active monitoring, 2.2% surgery, 2.9% radiotherapy — with no statistically significant difference between treatment approaches (P = 0.53).

Progression is usually slow and detectable with regular PSA tests, imaging, and biopsies.

Treatment remains effective when started at the right time; delaying does not reduce success rates.

"Active surveillance is carefully structured. We monitor your cancer closely and intervene only if needed. This approach balances safety with quality of life."

Dr Christos Mikropoulos, Oncologist

Voices from Men who have done active surveillance

“Active surveillance may be highly effective in monitoring cancer, but for me, it was doing my head in — constantly worrying, not sleeping properly, and with my mind taking me to some very dark places.”

Perry Letcher
The Focal Therapy Clinic patient

See more patient stories

Why Quality of Life Matters in Early Prostate Cancer

Surgery and radiotherapy can cause urinary, bowel and sexual side effects that many men may never need. Active surveillance helps preserve:

Continence

Active surveillance helps men maintain bladder control, avoiding urinary incontinence often associated with surgery or radiotherapy.

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Sexual Function

Monitoring early prostate cancer can preserve erectile function and intimacy, supporting healthy relationships.

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Day-to-Day Wellbeing

By avoiding immediate treatment, men can maintain energy, independence, and overall quality of life.

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The 12-year quality-of-life follow-up of the UK ProtecT trial showed that men in the active monitoring arm had the best urinary, sexual and bowel function outcomes compared with men who had immediate surgery or radiotherapy (Donovan et al., NEJM 2023).

Mr Marc Laniado: ‘When is it time to move from monitoring to treatment?

When Might Treatment Be Recommended?

It's important to know that routine monitoring helps your care team spot changes early — before they become urgent. Some common factors that may prompt further evaluation or consideration of treatment include:

Changes in PSA trends — A consistent rise or faster doubling of PSA levels can signal biological changes that warrant further investigation.
MRI evidence of progression — Radiological imaging may show changes in the prostate that suggest progression of disease or appearance of new areas of concern.
Biopsy findings - Results showing higher-grade disease or increased tumour involvement can be important signals that active treatment should be discussed.

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How Active Surveillance can lead to focal therapy

If Cancer Changes — But Stays Localised

Active surveillance carefully monitors your prostate health over time. If results show that the cancer has progressed but remains confined to one area of the prostate, treatment may be considered while the disease is still highly manageable.

A Targeted Treatment Approach

In appropriate cases, focal therapy can treat only the specific area of concern rather than the entire prostate. This precision approach focuses on controlling the cancer while minimising impact on surrounding healthy tissue.

Preserving Quality of Life

Because focal therapy is targeted, it is designed to reduce the risk of side effects often associated with whole-gland treatments. For many men, this approach supports continued urinary, sexual, and overall quality-of-life preservation.

At The Focal Therapy Clinic, transitioning from active surveillance to focal therapy is one of the most common care pathways. Mr Tim Dudderidge and Mr Raj Nigam — both FTC consultants and co-authors of the UK HEAT registry analyses on focal therapy outcomes (Reddy et al., European Urology 2022; Habashy/Reddy et al., J Urol 2023) — regularly treat men making this transition.

Why Choose The Focal Therapy Clinic for Active Surveillance?

At The Focal Therapy Clinic, we understand that this choice can feel overwhelming. Questions about PSA changes, scans, and future treatment options can create uncertainty. That’s why support, clarity, and expertise sit at the heart of everything we do.

Clear explanations of your results and what they mean

Structured, evidence-based monitoring protocols

Honest discussions about when — and if — treatment should be considered

Access to advanced focal therapy options if they become appropriate

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Questions to ask your doctor or nurse

Is active surveillance the right strategy for my specific cancer risk profile, or am I being offered it because of capacity issues?

What are the exact criteria for treatment to begin — what PSA, MRI or biopsy change would trigger a move to treatment?

How often will I have PSA tests, MRI scans, and biopsies? And who will review the results?

If I want to consider focal therapy now instead of waiting, am I eligible — or would that be premature?

What does the published evidence say about staying on active surveillance for men in my age group and with my Gleason score?

If I'm finding the monitoring period emotionally difficult, what support is available — and is that itself a reason to consider earlier treatment?

Bring these to your GP appointment, or speak to our team first.

Frequently asked questions

Is active surveillance the same as doing nothing?

No. Active surveillance is a structured, evidence-based monitoring programme — typically involving a PSA test every 3–6 months, an MRI scan every 1–3 years, and a repeat biopsy when imaging or PSA changes indicate it (PRIAS protocol; NICE NG131).

It is the opposite of “doing nothing”; it is treatment deferral with planned re-evaluation. Watchful waiting is a different strategy with a different clinical purpose — it involves much less testing and is used when curative treatment is unlikely to be tolerated or beneficial.

How long can you stay on active surveillance for prostate cancer?

There is no fixed time limit. Around half of men who start active surveillance remain treatment-free 10 years later (PRIAS registry; ProtecT trial 15-year follow-up, Hamdy et al., NEJM 2023).

Prostate cancer mortality at 15 years in the UK ProtecT trial was comparable across active monitoring, surgery, and radiotherapy — 3.1% vs 2.2% vs 2.9% — with no statistically significant difference.

How long you stay on surveillance depends on PSA trends, MRI findings, and biopsy results.

What happens if my cancer progresses during active surveillance?

Progression is usually slow and detectable through scheduled PSA tests, MRI scans, and biopsies — long before the cancer becomes dangerous.

If progression is confirmed, you and your specialist discuss treatment options. For many men, focal therapy becomes the preferred next step because the cancer is usually still localised and well-mapped, making targeted treatment possible.

Is active surveillance safe for younger men in their 50s and 60s?

Yes, for the right cancer profile. Low-risk and favourable intermediate-risk prostate cancer (Gleason 6 or favourable 3+4=7) in younger men can be safely monitored.

The decision weighs life expectancy against the years of monitoring required. Many younger men choose active surveillance initially and move to focal therapy if the cancer shows any progression — a strategy that minimises treatment side effects during their most active years.

Can I move from active surveillance to focal therapy at any time?

Yes — and many men do. The transition from active surveillance to focal therapy is one of the most common care pathways at The Focal Therapy Clinic.

Triggers include rising PSA, MRI evidence of progression, upgraded biopsy findings, or simply the patient’s own decision that monitoring is no longer right for them.

A specialist consultation will confirm whether focal therapy is technically possible for your specific cancer.

Is active surveillance safe even if it's making me anxious?

For men who find active surveillance psychologically difficult, the monitoring itself can affect quality of life — anxiety, sleep disturbance and the burden of ongoing tests are documented downsides.

If active surveillance is undermining your wellbeing and your cancer is suitable for focal therapy, moving to treatment is a clinically valid choice. This is something to raise with your specialist openly.

Is active surveillance available on the NHS?

Yes — active surveillance is a NICE-recommended strategy for low-risk and favourable intermediate-risk localised prostate cancer and is offered on the NHS (NICE NG131, 2021).

Private patients at The Focal Therapy Clinic receive the same evidence-based protocol but with shorter waiting times for scans and biopsies, direct consultant access, and a built-in pathway to focal therapy if and when it becomes appropriate.

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Any questions?

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

0207 036 8870

info@thefocaltherapyclinic.co.uk