After a prostate cancer diagnosis, your first instinct might be to seek treatment immediately. However, there are situations in which cancer specialists may recommend delaying treatment, at least temporarily. In about one-third of prostate cancer cases, doctors recommend watchful waiting — monitoring the cancer closely without treating it right away.

Watchful waiting might feel like inaction compared to starting cancer treatment immediately. But in fact, watchful waiting isn’t the same as “doing nothing.” In this article, we’ll talk about what watchful waiting looks like for people with prostate cancer and when your doctor may recommend starting treatment.

What’s the Goal of Watchful Waiting?

Watchful waiting, also called observation, is a strategy that involves tracking symptoms and following up with occasional tests after prostate cancer has been discovered. It’s a passive approach, but it can help many men avoid potential side effects and complications of cancer treatments that commonly impact quality of life.

The main goal of watchful waiting is to maintain the quality of life while tracking a prostate tumor’s growth and see if it causes symptoms or metastasizes (spreads to other parts of your body). Smaller prostate tumors that haven’t spread might not cause any symptoms, and treatment may not be necessary until they do. You’ll be advised to tell your doctor if you notice any new symptoms or changes related to your prostate cancer.

Active Surveillance vs. Watchful Waiting

Active surveillance is a step above watchful waiting in terms of monitoring. It involves more frequent tests and medical appointments to monitor prostate cancer for growth.

If your doctor recommends active surveillance instead of watchful waiting, you can expect to get a prostate-specific antigen (PSA) blood test every six months and a digital rectal exam (DRE) once a year or so. Your doctor might also recommend occasional prostate biopsies or imaging scans when taking this more active approach.

When Is Watchful Waiting Recommended for Prostate Cancer?

Doctors usually recommend watchful waiting for prostate cancer in specific situations, typically for people who:

• Have low-risk or favorable intermediate-risk prostate cancer
• Are older adults
• Have other serious health conditions

If you fall into one of these groups, your doctor may suggest watchful waiting (or active surveillance) if your cancer also meets certain criteria:

• You don’t have symptoms from your prostate cancer, such as pain or trouble urinating.
• Your cancer is slow-growing (considered low or favorable intermediate-risk based on its stage and molecular test results).
• The cancer is still confined to the prostate (hasn’t spread elsewhere in the body).
• The tumor is small.

For people with fast-growing, metastasized, and unfavorable intermediate to high-risk tumors, doctors are more likely to recommend starting treatment immediately.

Pros and Cons of Watchful Waiting for Prostate Cancer

Doctors may recommend watchful waiting when they believe the benefits are likely to outweigh the risks. This approach has both advantages and disadvantages. If your doctor suggests watchful waiting, ask them to explain what it could mean for you.

Pros of Watchful Waiting

Your doctor might suggest watchful waiting with the following benefits in mind.

Fewer Appointments and Tests

With watchful waiting, you mostly keep track of your own symptoms and let your doctor know if anything changes. This approach usually involves fewer tests and doctor visits than active surveillance. You won’t need regular treatment appointments unless your doctor decides it’s time to start treatment.

Avoiding or Delaying Side Effects

Cancer treatments like surgery, hormone therapy, and radiation can have uncomfortable side effects that lower your quality of life. By opting for watchful waiting, you can delay these side effects of treatment for years or perhaps avoid them.

Treating Symptoms Instead of Cancer Itself

If you eventually develop symptoms of prostate cancer, your doctor might give you options to treat the specific symptoms instead of undergoing harsh cancer treatments.

Possible Cons of Watchful Waiting

Some people might find the drawbacks of watchful waiting to be difficult to ignore.

Anxiety About Delaying Treatment

It may be difficult for you to sit with the uncertainty of having cancer without starting immediate treatment, even if you know the cancer is low risk and unlikely to cause problems. Your loved ones might feel some anxiety about this, too. Frequent tests and waiting for test results while on active surveillance might add to anxiety.

Undetected Cancer Changes

Rarely, prostate cancer begins growing faster than a prostate biopsy indicates, or unexpectedly becomes more aggressive. In these unusual cases, the cancer may be harder to treat than if you’d started treatment when it was first detected.

Monitoring During Your Watchful Waiting Period

Most of the time, watchful waiting involves tracking your own symptoms without getting regular tests like you would with active surveillance. However, your doctor might still ask you to come in for tests every once in a while to monitor the cancer’s growth. You likely won’t get regular imaging scans or biopsies, but your doctor might suggest one of more of the following.

PSA Blood Tests

PSA tests measure the amount of a protein called prostate-specific antigen in your blood. It’s normal to have a small amount of PSA, since all prostate cells produce it. However, prostate cancer cells can raise PSA levels even more.

High PSA levels can be caused by prostate cancer, but they can also be due to other reasons, such as an enlarged prostate, prostatitis (prostate inflammation), or even recent physical activity.

Digital Rectal Exams

During a DRE, your doctor uses a gloved finger to feel your prostate through your anus. Some very early-stage prostate tumors cannot be felt during a DRE but may become apparent once they grow.

Self-Monitoring of Symptoms

Perhaps the most important part of watchful waiting is your own symptom monitoring. You might not have any prostate cancer symptoms at first, but your doctor will tell you to get in contact if you notice any.

Let your doctor know if you experience any of the following prostate cancer symptoms:

• A frequent need to pee
• A weak urine stream
• Trouble urinating
• Blood in your pee
• Swelling in your legs
• Fatigue (extreme tiredness that doesn’t improve with rest)
• Unintentional weight loss
• Unexplained aches and pains

Experiencing these symptoms doesn’t automatically mean you’ll need prostate cancer treatment. They may not even be caused by prostate cancer. But you may need more tests to find out what’s happening.

When To Start Treatment

Your doctor might suggest starting treatment if you have symptoms and further tests have indicated that your cancer has grown or metastasized. They’ll tell you about your prostate cancer treatment options, and together, you’ll make an informed decision based on the details of your cancer and your preferences.

Prostate Cancer Treatment Options

There are many ways to treat prostate cancer with a goal of shrinking the tumor, removing it, or stopping the cancer from spreading. Common options include:

• Surgery
• Radiation therapy (also called radiotherapy)
• Hormone therapy
• Immunotherapy
• Targeted therapy

Some people may be eligible to join clinical trials. For those who have a shorter life expectancy due to age or other health conditions, doctors may recommend palliative treatment, which is focused on improving comfort and quality of life rather than curing or stopping the growth of cancer.

If you begin to notice potential prostate cancer symptoms during watchful waiting, talk to your oncology team right away. They can help determine whether the symptoms are related to the growth of prostate cancer and recommend next steps.

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