Scottish Cancer Network: Clinical Management Pathways
Active Surveillance (AS) is a program of interventions intended to monitor those individuals diagnosed with a prostate cancer that does not require immediate treatment, or for those who choose to defer immediate treatment. It is intended to be used for those people who would be suitable for, and who would benefit from radical treatment. This document will cover guidance on who is appropriate, the follow-up pathway and criteria for further investigation and treatment.
Active surveillance
Warning
This consensus document is not a rigid constraint on clinical practice, but a concept of good practice against which the needs of the individual patient should be considered. It therefore remains the responsibility of the individual clinician to interpret the application of these guidelines, taking into account local service constraints and the needs and wishes of the patient. It is not intended that these consensus documents are applied as rigid clinical protocols.
AS can be offered to men under the age of 80 who are suitable for radical treatment and have a life expectancy of more than 10 years. Risk stratification is based on the Cambridge Prognostic Group (CPG) 
criteria.
CPG 1 = Recommend Active Surveillance, consider radical treatment if patient does not wish Active Surveillance.
CPG 2 = Offer radical treatment equally with active surveillance. This would be dependent on volume of disease, prostate-specific antigen (PSA) and radiological staging. Those with greater than 20% Gleason pattern 4 disease should not be offered AS.
CPG 3 = Recommend radical treatment. Consider AS if patient wishes to defer treatment particularly where no visible disease is seen on MRI in patients with Gl pattern 3+4. May be considered after discussion at multidisciplinary team (MDT). Patients with Gleason pattern 4 disease in greater than 20% of tissue should not be offered AS. Patient should have been appropriately counselled as to the increased risk of progression prior to enrolment.
PCUK have published a Toolkit for Active Surveillance that may help inform patients about best treatment for them.
The Prostate PREDICT tool may also be of help in counselling men towards active surveillance.
Patients with perineural invasion (PNI) or Cribriform pattern should be discussed at an MDT to check suitability for AS.
All those enrolled should have a PSA check every 3-4 months either in primary or secondary care prompted by clinical team supervising AS programme (depending on local arrangements).
Review can be undertaken either face to face or by telephone/video call every 12 months. Digital rectal examination (DRE) can be considered every 12 months and is recommended for those not suitable for magnetic resonance imaging (MRI).
Repeat MRI scan (either multiparametric or bi parametric depending on local availability) at 12-18 months (especially for those with higher risk lesions suggested on initial diagnostic scan).
MRI scans should be reported using Prostate Imaging Reporting and Data System (PI-RADS), Likert or Prostate Cancer Radiological Estimation of Change in Sequential Evaluation (PRECISE) scoring system and include a prostate volume and PSA density.
MRI scanning should be performed when PSA is rising consecutively, or DRE suggests progression. Consideration can be given to more regular scanning for those on AS in CPG 3 or where other parameters increase concern about risk of progression.
Repeat biopsy in the form of Trans Perineal or Transrectal ultrasound scan (TRUS) can be arranged if it will help inform decision making when MRI, PSA or DRE raise concern of potentially progressive disease.
Patients should be moved to a treatment pathway when >20% Gleason pattern 4 is noted, PSA density ≥0.2, MRI lesion >10mm. Consider moving to a treatment pathway if PSA is persistently rising towards a PSA density of 0.2 or with a shortening doubling time or if the patient wishes to stop AS
Follow up should continue until the age of 80 or comorbidities would exclude radical treatment as a beneficial option. Refer to local Watchful Waiting (WW) pathway.
The STRATCANS tool is available as an aid to decisions on timing of review and repeat scans during follow up.
Watchful Waiting (WW) is a way of monitoring, through a non-curative pathway, prostate cancer that isn't causing any symptoms or signs of advanced disease. Patients should be fully counselled as to the ‘non-radical’ intent of WW, as opposed to the ‘radical’ intent of AS prior to enrolment. Suitability for WW will be case by case dependent on advancing age and comorbidities. A WW protocol will generally involve a 6-12 monthly PSA test through the GP practice with the results monitored in secondary care and further investigation initiated when PSA is rising quickly on consecutive testing, or patient is symptomatic of metastatic disease.
Treatment should be initiated when advanced disease is demonstrated or PSA doubling time is <3 months, or metastases are evident on imaging (bone scan or CT; no role for MRI in these patients). This will be in the form of hormonal therapy which can be initiated on specialist advice in either primary or secondary care.
For more information about treatment with androgen deprivation therapy, refer to the SACT pathway.
Patients who have undergone High-Intensity Focused Ultrasound (HIFU) (either whole gland or focal therapy) should be followed up locally using the AS protocol. If the treating centre wishes further assessments outwith this protocol they should be arranged by the treating centre.
- Getting it Right First Time GIRFT - Towards better diagnosis management of suspected prostate cancer.pdf [PDF only]
- NICE Guidance on Prostate cancer: diagnosis and management
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The STRATCANS tool