Active Surveillance: When Your Doctor Wants to Monitor, Not Immediately Treat, Your Cancer

Today, not all cancer is actively treated. Some slow-growing cancers may be monitored closely to determine if treatment is ever needed. This approach is called active surveillance. We talked to UNC REX medical oncologist Ranjit Joseph, MD, to learn more.

What is active surveillance?

Active surveillance is a management strategy where certain cancers are monitored carefully in order to delay or avoid treatment in people who don’t need treatment right away. We use this strategy in situations where delaying treatment for cancer won’t hurt people and, in many cases, can help them avoid treatment and its potential side effects entirely. The other aspect of active surveillance is to detect cancer progression early and intervene when necessary.

When is active surveillance an option?

Active surveillance may be an option if the cancer is slow growing, if treatment may have more side effects than the cancer itself and where delaying treatment is unlikely to cause harm.

Is it possible to spend your life under active surveillance and not ever undergo treatment?

Yes, sometimes there are people we can monitor for a very long time, and some may have cancers that may never need to undergo treatment.

What is the most common type of cancer for which active surveillance is used?

This strategy is most commonly used and preferred for men with very low-risk prostate cancer with a life expectancy of 20 years or greater and low-risk prostate cancer with a life expectancy of 10 years or greater.

In other words, if a person is only expected to live another 10 years and has a very low-risk cancer, we can cure him or her with radiation or surgery, but there are a number of side effects from treatment that could be avoided if we use active surveillance instead. These include complications of surgery, urinary incontinence and erectile dysfunction.

For what other types of cancer is active surveillance an option?

We use active surveillance in most stage 1 testicular cancers after the initial surgery to remove the cancer if we feel that the person will obey strict follow-up care that include labs, exams and imaging at specific times for several years. The idea here is that only a small number of people have cancer come back, and by treating everyone with chemotherapy, we would have treated a lot of patients unnecessarily. Of course, any active surveillance treatment plan is only helpful if the person is able and willing to come for follow-up appointments regularly.

We also use active surveillance for some patients with chronic lymphocytic leukemia (CLL) and for some slow-growing lymphomas, such as low-grade follicular lymphoma and nodular lymphocyte-predominant Hodgkin lymphoma. In people with CLL or other stage IV slow-growing lymphomas that do not cause any symptoms, we would only start treatment if they begin to experience significant symptoms from the disease, they are at risk of organ damage, they have low blood counts or their cancer starts to grow more rapidly.

About a third of patients with CLL may never need treatment, and another third may be able to delay treatment until several years down the road. A recent study showed that a select group of patients with nodular lymphocyte-predominant Hodgkin lymphoma have an excellent prognosis, and therefore active surveillance could be a viable initial strategy for those patients.

How often would a patient under active surveillance see his or her doctor, and what would the visit entail?

It depends on the type of cancer. In people with prostate cancer undergoing active surveillance, they typically would have a checkup every six months to a year. This visit would include a PSA (a blood test to measure the patient’s level of prostate-specific antigen, a substance that can be high in men with prostate cancer), a physical exam and a rectal exam, and a prostate biopsy no more than once a year

Can a patient request treatment even if active surveillance is recommended?

Yes. It can be incredibly nerve-racking to think you have cancer and your doctor wants to wait. That’s why it’s important to have an informed discussion with the doctor about what the risks and benefits are of active surveillance or proceeding with treatment. We try our best to identify people appropriately so that we’re giving treatment to the ones that really need it and avoid potentially over-treating patients. But after an informed discussion, we allow people to make their decision.

To learn more about your cancer risk, talk to your doctor. If you need a doctor, find one near you. If you have received a cancer diagnosis and want to learn more about active surveillance, find an oncologist near you.