What are the recommended follow-up protocols for patients diagnosed with localized prostate cancer?

Follow-up protocols for patients diagnosed with localized prostate cancer depend on the chosen management strategy: active surveillance, radical treatment, or watchful waiting.

Active Surveillance:

• In the first year, measure prostate-specific antigen (PSA) every 3 to 4 months; PSA kinetics (including density and velocity) should be monitored throughout surveillance. A digital rectal examination (DRE) should be performed at 12 months by a trained healthcare professional. Multiparametric MRI is recommended at 12 to 18 months. If clinical or PSA changes raise concern at any time, reassessment with multiparametric MRI and/or re-biopsy should be done.
• From year 2 onwards, PSA should be measured every 6 months, with continued monitoring of PSA kinetics. DRE should be performed annually. This protocol aims to detect disease progression early and guide decisions about moving to radical treatment if needed.

Radical Treatment (e.g., prostatectomy, radiotherapy):

• PSA levels should be checked no earlier than 6 weeks after treatment, then at least every 6 months for the first 2 years, and at least annually thereafter.
• Routine DRE is not recommended for patients not on active surveillance if PSA remains at baseline levels.
• After at least 6 months of stable follow-up without significant complications, remote follow-up strategies may be considered unless the patient is enrolled in a clinical trial requiring clinic visits.

Watchful Waiting:

• PSA should be measured at least once a year in primary care under agreed shared-care protocols.
• Routine DRE is not recommended while PSA remains stable at baseline levels.
• Patients showing signs of significant disease progression (e.g., rapidly rising PSA or bone pain) should be referred back to a urological cancer specialist.

Additional considerations: Follow-up discussions should include the purpose, duration, frequency, and location of follow-up, and patients should be advised about potential long-term adverse effects of treatment and how to report them.

This follow-up approach balances early detection of progression with minimising unnecessary interventions and supports shared decision-making based on patient preferences and clinical status.

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