Active Watching of Prostate Cancer is Usually Safe, but Not Always

Prostate cancer usually grows slowly over many years, so a study was designed to find out if it is safe to delay treatment for many years. More than 1,600 men diagnosed with localized prostate cancer (that had not spread beyond the prostate) were randomly assigned to receive surgery, radiation or waiting with active monitoring. Fifteen years later, there was no statistical difference in deaths from prostate cancer between the three groups: 3.1 percent in the active-waiting group, 2.2 percent in the surgery group, and 2.9 percent in the radiation group. More than 97 percent of the men were still alive, regardless of which treatment they received (NEJM, March 11, 2023). All the men were closely monitored by their doctors and some went on to require surgery or radiation. Cancers had spread in 9.4 percent of the active waiting group, seven percent of the surgery group and five percent of the radiation group (again, no statistically significant difference).

Rationale for Delaying Prostate Cancer Treatment
Many other studies have also found that long-term active waiting for localized prostate cancer can be safe (JAMA Netw Open, 2022;5(9):e2231015). Prostate cancer treatments often cause incontinence and problems with getting or maintaining an erection. Eighteen or more months after surgery to remove the prostate, 8.4 percent of men were incontinent and 59.9 percent were impotent (JAMA, Jan 19, 2000;283(3):354-60). About 60 percent of low-risk patients choose active surveillance. However, some conditions and high-grade prostate cancers may require immediate treatment with surgery or radiation.

My Recommendations
Prostate cancer usually does not kill a man as long as it stays in the prostate; it kills by spreading to another organ and destroying that organ. The most common metastatic sites are bone (84 percent), distant lymph nodes (10.6 percent), liver (10.2 percent), or thorax (9.1 percent). Overall, 18.4 percent of patients who had prostate cancer spread had multiple metastatic sites (Prostate, Feb 2014;74(2):210-6). However, your doctor may reject active waiting and find reasons to recommend immediate treatment with surgery or radiation. Communicate with your doctor to determine whether you need earlier treatment.