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Watchful waiting in prostate cancer

Last reviewed dd mmm yyyy. Last edited dd mmm yyyy

Authoring team

Watchful waiting and Active Surveillance are both forms of monitoring described in the NICE guidance (1).

Watchful waiting

  • watchful waiting involves the conscious decision to avoid treatment unless symptoms of progressive disease develop. Those men who do develop symptoms of progressive disease are usually managed with hormonal therapy. This approach is most often offered to older men, or those with significant co - morbidities who are thought unlikely to have significant cancer progression during their likely natural life span
  • the steps in 'watchful waiting' are not specifically outlined in the NICE guidance but have been summarised as (2):
    • waiting usually involves check-ups at the GP surgery rather than at the hospital. Check-ups usually happen less often than with active surveillance. The aim is to treat the cancer if it starts causing problems or symptoms.
  • NICE suggest that a member of the urological cancer MDT should review men with localised prostate cancer who have chosen a watchful waiting regimen and who have evidence of significant disease progression (that is, rapidly rising PSA level or bone pain)

Active surveillance

  • active surveillance should be offered as an option to men with low-risk localised prostate cancer for whom radical prostatectomy or radical radiotherapy is suitable
  • consider using the protocol in table below for men who have chosen active surveillance
  • consider active surveillance for men with intermediate-risk localised prostate cancer who do not wish to have immediate radical prostatectomy or radical radiotherapy
  • do not offer active surveillance to men with high-risk localised prostate cancer

Comparison of Active Surveillance versus Watchful Waiting

Active surveillance

Watchful waiting

  • part of a 'curative' strategy and is aimed at people with localised prostate cancer for whom radical treatments are suitable, keeping them within a 'window of curability' whereby only those whose tumours are showing signs of progressing, or those with a preference for intervention are considered for radical treatment.
  • active surveillance may thus avoid or delay the need for radiotherapy or surgery.
  • part of a strategy for 'controlling' rather than 'curing' prostate cancer and is aimed at people with localised prostate cancer who do not ever wish to have curative treatment, or it is not suitable for them
  • involves the deferred use of hormone therapy
  • watchful waiting avoids the use of surgery or radiation, but implies that curative treatment will not be attempted.


Protocol for active surveillance


Tests a

Year 1 of active surveillance

Every 3 to 4 months:

  • measure prostatespecific antigen (PSA)b
  • Throughout active surveillance: monitor PSA kineticsc
  • At 12 months: digital rectal examination (DRE)d
  • At 12 to 18 months: multiparametric MRI

Year 2 and every year thereafter until active surveillance ends

Every 6 months:

  • measure PSAb
  • Throughout active surveillance: monitor PSA kineticsc
  • Every 12 months: DREd


a If there is concern about clinical or PSA changes at any time during active surveillance, reassess with multiparametric MRI and/or re-biopsy.

b Could be carried out in primary care if there are agreed shared-care protocols and recall systems.

c Could include PSA density and velocity.

d Should be performed by a healthcare professional with expertise and confidence in performing DRE. In a large UK trial that informed this protocol, DREs were carried out by a urologist or a nurse specialist.


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