Assessment and monitoring of early prostate cancer at Gota OPD, Ahmedabad · Surgery, where it becomes necessary, at Apollo Hospital, Bhat, Gandhinagar
When prostate cancer is found early and carries every low-risk feature, the recommended first treatment is not an operation and not radiation — it is a monitoring programme that keeps the cancer under close watch and treats it only if it starts to behave differently. This is called active surveillance, and it is a decision taken deliberately, with a written calendar of tests. It is not “we will wait and see”, and it is not the doctor doing nothing because the family cannot afford surgery.
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Dr Swati Shah
MS, DrNB (Surgical Oncology)
Prostate Cancer Surgeon · Apollo Hospital, Bhat, Gandhinagar · Gota OPD, Ahmedabad
Shah’s Gastro, Cancer & Robotic Surgery Centre. A surgeon who offers surveillance is a surgeon telling a man he does not need the operation she is trained to perform. That is only credible from someone who does this operation regularly, knows exactly what it costs a man in continence and in sexual function, and can therefore say honestly when it is worth paying and when it is not yet.
Low risk is not a description of how you feel or how big the prostate is. It is a precise combination of three findings, and all three must be true together: a PSA below ten, a biopsy graded ISUP Grade Group 1, and a tumour that the examining finger and the scans place within the gland as cT1 or cT2a.
If any one of those three is worse, the disease is not low risk, and the conversation is a different one. A man with a Grade Group 1 biopsy and a PSA of fourteen is intermediate risk because of the PSA alone. A man with a PSA of six whose biopsy shows Grade Group 2 is intermediate risk because of the grade. This matters because families arrive having been told “it is only early cancer” by someone reading one line of the report rather than three.
One change to be aware of, because older printed material and older templates still carry it: the category once called very low risk has been removed from the 2026 guidance. If a report or an opinion letter still uses that phrase, it is working from a superseded classification, and the grouping should be re-derived from the PSA, the grade group and the stage.
Radical prostatectomy and radiotherapy both cure low-risk prostate cancer. That is not in dispute, and it is why men are so often pushed straight towards one of them. The difficulty is that this particular version of the disease, left under proper observation, very rarely becomes the thing that ends a man’s life — while the two treatments that cure it carry consequences that begin the week they are given and frequently never fully reverse.
Those consequences are not abstractions. Urinary leakage requiring pads, for a period that is measured in months rather than days. Erections that change, and in many men do not return to what they were. Ejaculation that ends permanently after prostatectomy. A recovery that takes a man out of his work. None of that is a reason to refuse treatment when treatment is needed — it is a reason not to spend it on a cancer that was never going to trouble him.
The honest framing is this: with low-risk disease you are not choosing between treatment and no treatment. You are choosing between paying the cost of treatment now, and keeping that cost in reserve for the day the cancer shows it has earned it.
The standard candidate has Grade Group 1 disease, a clinical stage of cT1c to cT2a, a PSA under ten, a PSA density below 0.15, and only a limited number of biopsy cores involved.
The part most often missed is that surveillance is no longer restricted to Grade Group 1. Selected men with Grade Group 2 disease, low volume on biopsy and a favourable MRI can also be surveilled — the guidelines now say so explicitly. A man told at another hospital that Grade Group 2 automatically means an operation is being given the previous decade’s advice.
Equally important is the list of men who must not be surveilled, whatever the PSA says:
Where the choice between surveillance and radical treatment is genuinely balanced, the case is taken to the tumour board and discussed with surgery and radiation oncology in the room together, so that the man hears the case for each from the people who actually believe in it, rather than hearing only from whichever specialist he happened to reach first.
A patient describes the route from his first urinary symptoms through investigation to treatment. Every man on surveillance is watching for the point at which this becomes his path too — and most never reach it.
Active surveillance has a fixed schedule, and following it is the treatment. A man on surveillance who attends is being treated. A man on surveillance who stops attending is untreated, and that — not the biology of the cancer — is how this pathway fails.
| Test | How often | What it is looking for |
|---|---|---|
| PSA blood test | Every six months | A trend, not a single figure. The pattern over several readings is what carries meaning |
| Digital rectal examination | Once a year | A change in the feel or the outline of the gland |
| MRI of the prostate | At twelve to eighteen months | A lesion that has grown, or a new one, or a change suggesting spread beyond the capsule |
| Confirmatory biopsy | Within the first twelve months | Disease the first biopsy under-sampled — the commonest reason a man is moved off surveillance early |
| Repeat biopsy thereafter | Every two to four years, or sooner on a change in PSA or MRI | Grade progression |
The confirmatory biopsy within the first year is the part men most want to negotiate away, and it is the part least open to negotiation. A prostate biopsy samples a small fraction of the gland. The first one establishes that low-grade cancer is present; the second establishes that higher-grade cancer is not present somewhere the first needles missed. Until that second biopsy, surveillance is being conducted on an incomplete picture.
There are three triggers, and only three: the biopsy grade goes up, the imaging shows real progression, or the man decides he no longer wants to live with it. A rising PSA on its own is not one of them.
That last point saves a great many men from an unnecessary operation. PSA moves for reasons that have nothing to do with cancer — an infection, a recent catheter, a long ride on a two-wheeler before the blood draw, inflammation in the gland. A single higher reading is answered by repeating it, imaging if the trend holds, and biopsying if the imaging or the trend warrants it. It is not answered by booking theatre.
When a trigger is genuinely met, the disease is restaged and the full range of treatment is still open — surgery with node dissection where indicated, or radiotherapy. Nothing has been lost by the waiting. That is the central fact families ask about most anxiously, and it is the reason surveillance is safe to offer: the men who come off it are treated with the same intent to cure as if they had been treated on the first day.
Treatments that destroy only part of the prostate — by heat, cold, ultrasound or electricity — are marketed hard to exactly the men who qualify for surveillance, because those men are looking for something in between doing nothing and a full operation. The 2026 guidance explicitly counsels caution in using focal therapy in newly diagnosed patients.
Outside a documented research protocol, it is treated here as investigational. Every request is taken to the tumour board rather than declined at the desk, and the discussion is an honest one: a man offered focal therapy is being offered something that has not yet shown it does what surveillance and radical treatment are each already known to do. If a centre is offering it as routine care for early disease, ask what protocol it is being given under, and what the plan is if the treated area recurs.
Where the family history includes prostate, breast, ovarian or pancreatic cancer, germline genetic testing is discussed, because a positive result changes both the advice to the man and the screening offered to his relatives — and cascade testing of first-degree relatives is tracked through to completion rather than mentioned once and forgotten.
Surveillance replaces the cost of an operation with the recurring cost of monitoring: a PSA twice a year, an MRI in the first eighteen months, and biopsies under anaesthesia at intervals. The first year is the most expensive year of surveillance, not the cheapest, because it carries both the MRI and the confirmatory biopsy.
Insurance behaves differently for surveillance than for surgery, and it is worth understanding before you choose. An admission for a biopsy under anaesthesia is usually claimable; a PSA test in OPD usually is not. Families who assume surveillance is free are surprised by the cumulative outpatient cost, and families who assume it is unaffordable are surprised by how much less it is than an operation. The hospital’s insurance desk will tell you which parts of your own policy respond, and an estimate for each step is given in writing before anything is booked.
★★★★★
“Dr. Swati is one of the best uro oncologist doctors. She explains everything nicely and gives honest advice. She treats kidney cancer, prostate cancer, bladder cancer and does advanced laparoscopic and robotic surgeries also. Patients feel very comfortable with her and trust her treatment. Highly recommended for any urology cancer problem.”
Gajendra Sharma, November 2025
★★★★★
“Dr. Swati Shah is an excellent robotic uro oncologist. Her expertise in prostate cancer treatment and robotic prostatectomy is truly commendable. She explains every step clearly and ensures comfort throughout the process. Highly recommended for anyone seeking advanced and precise prostate cancer care.”
Preeti D. yajnik, October 2025
★★★★★
“Excellent...it's too good experience with Dr Swati shah mam...I came to her unknowingly for my prostate surgery.. a satisfied explanation before surgery , successful surgery and post surgery explanation and care is best....I am thankful to Calm , Quick , Clever Dr.swati shah mam🙏🏻”
Raj Patel, January 2025
For this particular grade and stage, yes — provided it is genuinely watched. Grade Group 1 prostate cancer confined to the gland grows slowly and very seldom spreads while it is being monitored on schedule. The safety comes from the schedule, not from the biology alone, which is why the confirmatory biopsy and the six-monthly PSA are not optional parts of it.
No. A rising PSA on its own is not a trigger for treatment. It is repeated, because PSA moves with infection, inflammation, a recent catheter and even a long two-wheeler ride before the blood test. If the trend is real, the next steps are an MRI and a biopsy — treatment follows a change in grade or clear progression on imaging, not a number on one report.
No. That is precisely what the monitoring exists to prevent. The triggers are set so that treatment begins while the disease is still curable, and men who come off surveillance are treated with the same intent to cure — surgery with node dissection where indicated, or radiotherapy — as men treated on the day of diagnosis.
Not automatically, not any more. Selected men with Grade Group 2 disease, low volume on the biopsy and a favourable MRI can be surveilled, and the current guidance says so explicitly. What does rule it out at any grade is a cribriform or intraductal pattern in the report. Bring the full pathology, not the summary line.
For as long as the disease stays unchanged, which for many men means indefinitely. There is no point at which you are discharged and told to stop testing. If attending twice a year for the rest of your life is not realistic for you, say so at the first consultation — that is a genuine reason to choose treatment instead, and it is better said early than discovered after three missed appointments.
Consultation at Gota. Surgery at Apollo, Bhat, Gandhinagar.
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