Decision-Making in Prostate Cancer

Choosing Active Surveillance Over Other Treatment Options: A Literature Review

David R. Bayliss, BN (Hons), RN; Jed Duff, PhD; Philip Stricker, MBBS, FRACS; Kim Walker, PhD


Urol Nurs. 2017;37(1):15-22. 

In This Article

Abstract and Introduction


A literature review was done using the Cognitive-Social Health Information Processing (C-SHIP) framework to identify how and why men diagnosed with prostate cancer choose active surveillance over other treatment options. Findings indicated men who choose active surveillance have a stronger preference for active or collaborative decision-making than those who choose other treatments. Men primarily choose active surveillance to avoid the side effects of incontinence and erectile dysfunction. This literature review informed the study by Bayliss, Duff, Stricker, and Walker (2016) and found physician recommendation to be the most influential factor when patients make a treatment decision.


Cancer is of significant concern worldwide and costs the Australian health system $3.8 billion annually (Cancer Counsel Australia, 2013). According to the American Cancer Society (ACS) (2016), in the United States, there will be nearly 61,360 new cases of prostate cancer diagnosed in 2017 and about 26,730 deaths from the disease.

Prostate cancer accounts for 30% of male cancers and 17% of all cancers nationally in Australia (AIHW, 2012). It is one of the most common cancers in the world. One in seven American men will be diagnosed with prostate cancer in his lifetime. Although common, the mortality rate of men (less than 85 years) with prostate cancer is relatively low, at one in 39 (ACS, 2016).

When deciding on a prostate cancer treatment, the optimal outcome is threefold: to maintain urinary continence, avoid erectile dysfunction, and be cured of the disease. Unfortunately, this is not always possible. Men and their partners receive data and advice from varying sources (media, Internet searches, physicians and other healthcare providers, other men who have prostate cancer, family, and friends). They may consider this information, weigh their priorities, and choose a treatment modality. There are a number of options, each with different risks and benefits. The decision-making process is often difficult and confusing, especially given the relatively few comprehensive resources that objectively compare all treatment options. This may exist because there is no consensus on the "best" treatment available to guide physicians and patients because no large randomized controlled trials include all treatment options due to the scale, complexity, and ethical barriers to such a study.

Several treatments are available for prostate cancer, including active surveillance, external beam radiation, high- or low-dose brachytherapy, open radical prostatectomy, robot-assisted prostatectomy, and hormonal ablation. The side effects of these treatments vary and can include high-volume blood loss, erectile dysfunction, urinary incontinence, and incomplete cure or removal of the disease. Despite this, surgery remains the most commonly received treatment for localized prostate cancer (Gardiner et al., 2012).

Active surveillance is a viable option for relatively healthy men with low-grade prostate cancer (Gleason score less than 6 or 7, prostate-specific antigen [PSA] less than 10) who have a life expectancy of greater than 10 years (Davison, Oliffe, Pickles, & Mroz, 2009). Active surveillance is often incorrectly described by patients and even some researchers as "doing nothing" (Bailey, Wallace, & Mishel, 2007; O'Rourke, 1999, Xu, Dailey, Eggly, Neale, & Schwartz, 2011). One researcher said to a patient: "Did anyone ever give you the option of doing nothing, just watchful waiting?" (Chapple et al., 2002). Active surveillance is choosing to delay active treatment (prostatectomy, radiation, hormonal ablation) and the accompanying side effects and inherent risks until the cancer progresses to a stage necessitating more intrusive and aggressive treatment (Davison et al., 2009). Most prostate cancer grows slowly; thus, this could be 10 years or more from diagnosis (Siemens, 2003). Should it become apparent during PSA surveillance (generally every 6 months) and confirmed by prostate biopsy (every 1 to 2 years) that the cancer has spread or become more aggressive, invasive treatment becomes a more desirable option (Davison et al., 2009).

Fewer than 5% of patients on active surveillance have cancer that will become untreatable (Stricker, 2013). By contrast, watchful waiting is best described as palliative care when the patient is sufficiently unwell or if the cancer spread is so extensive that cure is not a viable option; in these situations, symptom relief is the primary care goal (Davison et al., 2009). The difference between active surveillance and watchful waiting is an important one; however, it is often unclear to patients. The terms are often used interchangeably in the literature, which causes more confusion. For this literature review, "active surveillance" and "watchful waiting" have been clearly distinguished based on the above definitions. Where authors have used the terms incorrectly but have clearly identified how they define the terms (such as Chapple et al., 2002, who defined watchful waiting as delaying treatment until monitoring identifies active treatment as recommended), the article was included with the understanding that although the terms have been incorrectly used, the definition was accurate.

Decision-making in healthcare settings, and more specifically, within nursing, has been well researched, especially in the area of breast cancer (Ménard, Merckeart, Razavi, & Libert, 2012; Miller, 1998; Shaw et al., 2008). When making decisions about cancer treatment, men and women are guided by different preferences and perspectives. Decisions are affected by both internal and external considerations. Patients must weigh the risks of treatment and its consequences for both themselves and those close to them. This is especially true for patients with prostate cancer because there are many treatment options, most of which involve potential side effects that may also impact their partners.