Active Surveillance in Urologic Cancer: When Doing Less Is the Right Decision
This article forms part of Dr Deanne Soares’ urologic cancer education series, providing evidence-based guidance on treatment, recovery and life after urological cancer surgery.
For many people, a cancer diagnosis creates an immediate expectation that treatment must follow quickly — and that decisive action is always better than waiting.
In urologic cancer care, that assumption is not always correct.
For selected patients, active surveillance is not avoidance, denial or delay. In carefully chosen situations, it allows time to observe cancer behaviour without compromising the opportunity for effective treatment if it becomes necessary.
This article explains what active surveillance means in urologic cancer, when it is recommended, and how decisions are made between surveillance and intervention.
Patient summary
Key points to know:
Active surveillance is structured monitoring, not “doing nothing”
It is appropriate for selected low-risk cancers
Treatment remains an option if the cancer changes
Surveillance aims to preserve quality of life
Decisions are individualised and revisited over time
What is active surveillance?
Active surveillance involves regular, planned monitoring of a known cancer rather than immediate treatment.
Depending on the cancer type, surveillance may include:
blood tests (such as PSA)
imaging
biopsies at defined intervals
clinical review
The goal is to detect meaningful change, not to ignore disease.
Active surveillance is different from watchful waiting, which is typically used when treatment would not be offered even if progression occurred. Surveillance assumes treatment is available and will be used if indicated.
Why surveillance exists in modern cancer care
Not all cancers behave the same way.
Some urologic cancers:
grow very slowly
may never cause symptoms
may never threaten life expectancy
For these cancers, immediate treatment can expose patients to side effects without clear benefit.
Surveillance recognises that:
overtreatment causes harm
quality of life matters
timing of treatment can influence outcomes
This approach has evolved alongside better imaging, improved pathology and long-term outcome data.
Where active surveillance is commonly used
Prostate cancer
Active surveillance is most established in low-risk prostate cancer and selected favourable intermediate-risk cases.
It may be appropriate when:
cancer is low grade
disease volume is limited
imaging does not suggest aggressive features
PSA behaviour is stable
the patient is comfortable with close monitoring
For many men and people with prostates, surveillance allows years — and sometimes lifelong — avoidance of surgery or radiation.
Kidney cancer
Small renal masses are increasingly detected incidentally.
Active surveillance may be considered when:
tumours are small
imaging suggests indolent behaviour
growth rates are slow
surgery carries higher risk due to comorbidities
Surveillance in kidney cancer focuses on tumour behaviour over time, with surgery offered if growth or features change.
Bladder cancer (selected contexts)
Surveillance is also part of bladder cancer management in specific low-risk, non-muscle-invasive cases, where recurrence patterns are predictable and monitored closely.
It is important to address common misconceptions.
Active surveillance is not:
denial of cancer
lack of follow-up
avoiding difficult decisions
appropriate for high-risk disease
Surveillance is structured, intentional and requires commitment from both patient and clinician.
How decisions about surveillance are made
Choosing surveillance depends on three overlapping domains:
1. Cancer characteristics
grade and stage
imaging features
growth patterns
pathological markers
2. Patient factors
age and overall health
other medical conditions
baseline function
personal priorities and tolerance of uncertainty
3. System capability
access to regular monitoring
reliable follow-up
clear triggers for intervention
All three must align for surveillance to be safe.
The psychological side of surveillance
One of the most underestimated aspects of active surveillance is the mental load.
Some patients find reassurance in avoiding treatment side effects. Others worry that waiting means losing control, which is why surveillance works best when the plan, review points and triggers for action are clearly defined from the outset.
Neither reaction is wrong.
Successful surveillance includes:
clear education
predictable follow-up schedules
honest discussion about risk
permission to reconsider
Choosing surveillance does not lock patients into that decision indefinitely.
When surveillance stops being the right choice
Surveillance is not static.
Treatment may be recommended if:
cancer grade changes
growth accelerates
imaging becomes concerning
symptoms develop
patient priorities shift
Transitioning from surveillance to treatment is not a failure. It reflects a decision being updated in response to new information — which is exactly how surveillance is intended to function.
Surgical judgement and experience
In practice, active surveillance works best when offered by clinicians experienced in both operative and non-operative cancer management, who are comfortable recommending restraint when appropriate and intervention when necessary.
For patients: questions worth asking
If surveillance is discussed, helpful questions include:
What specifically are we monitoring?
How often will tests occur?
What would trigger treatment?
What are the risks of waiting in my case?
Can I change my mind later?
Clear answers reduce anxiety and improve confidence.
For GPs and referring clinicians
GPs play a crucial role in supporting patients on surveillance by:
reinforcing that surveillance is active care
helping manage test-related anxiety
monitoring general health and comorbidities
facilitating timely re-referral if concerns arise
Consistent messaging across care teams prevents unnecessary distress.
A note on individual decision-making
This information is intended to provide general guidance on active surveillance in urologic cancer, but it cannot replace an individual consultation. Decisions about surveillance depend on cancer characteristics, monitoring capability and patient priorities, and are best made through discussion with the treating team.
Conclusion
Active surveillance reflects a shift in modern cancer care — away from reflexive treatment and toward thoughtful, individualised decision-making.
For selected patients, doing less initially does not mean caring less — it means choosing treatment timing carefully, rather than reflexively.
Good cancer care is not defined by how quickly treatment is delivered, but by how appropriately it is chosen.
About the author:
Dr Deanne Soares is a Melbourne-based urologist with a subspecialist focus in robotic prostate, kidney and bladder cancer surgery.
