Rajan: Active surveillance, MRI, and a changing decision in prostate cancer
When prostate cancer doesn't need immediate surgery, and how to weigh active surveillance with your urologist
Prof. Prabhakar Rajan with Dr. Karan Rajan
Page synthesised Jun 21, 2026·Last reviewed Jun 21, 2026
What this episode covers
- Prostate cancer is often present without symptoms, especially in earlier stages, and is the most common male cancer in many countries.
- Modern urology is moving away from automatic surgery toward active surveillance, MRI-guided diagnostics, and personalized risk scoring, which may spare some men the side effects of treatment.
- Earlier conversations about screening may matter more for men with above-average genetic or ethnic risk.
Why it matters
If treatment side effects can include incontinence, sexual function loss, and changes to relationships and mental health, then how a diagnosis is made and what is done next has implications far beyond the prostate itself.
What stands out
- Many older men carry some prostate cancer that may never cause harm, with up to 80 percent of men in their eighties showing some prostate cancer on post-mortem studies (autopsy studies).
- A high PSA is often taken to mean cancer, but it can rise from infection, ejaculation, or cycling, and a low PSA does not rule out a clinically significant cancer (clinical practice + MRI studies).
- Most men assume surgery is the default for prostate cancer, but the long-term trial evidence shows that decision style matters more than speed; even when cancer is found, the slow-growing nature of many cases leaves real room for a personalized choice between active surveillance and treatment rather than automatic intervention (ProtecT trial 15-year follow-up + European screening trial 23-year follow-up).
Best-supported action
The single highest-leverage move from this episode, anchored in the strongest evidence the speaker presents.
Consider asking your GP from age 45 onwards (or earlier if you have higher genetic or ethnic risk) for a structured conversation about prostate health that covers what a PSA test would and would not tell you in your case.
Other supported actions
Further actions discussed in this episode, ordered from strongest to weakest evidence. This is one expert's view, the full topic compares and ranks across experts.
- Consider asking your GP for a structured conversation about prostate health that covers your age, family history, ethnicity, and any urinary symptoms before deciding whether to do a PSA test. This sets a clear baseline and avoids the common trap of testing without a plan for what to do with the result.Strong evidence
- If a PSA is elevated or there is a clinical reason for concern, consider asking your specialist whether an MRI scan should come before any biopsy, since MRI can sometimes identify clinically significant tumors that PSA misses and can avoid unnecessary biopsies in other cases.Moderate evidence
- If diagnosed with early-stage, low-grade prostate cancer, consider asking your urologist and ideally a second opinion whether active surveillance fits your case before agreeing to surgery or radiotherapy. The right choice depends on age, life expectancy, tumor characteristics, and which side-effect risks matter most to you.Strong evidence
Full context, impact ratings, and timing — available in related topics
Questions to take to your doctor
- Given my age, family history, and ethnicity, would a PSA test now meaningfully change what we do, or would it mainly add noise we then have to interpret?
- Given my elevated PSA result, do you recommend MRI before biopsy, and what would change in our plan based on what the scan shows?
- Given a diagnosis of early-stage prostate cancer, what are the criteria you would use to recommend active surveillance over surgery or radiotherapy in my case?
Full doctor prep with ranked questions available in the full topic page
Context
Academic urologist and researcher focused on prostate and testicular cancer, with work on early-detection biology and polygenic risk modeling. Tends to view modern prostate cancer care as a personalized risk-stratification problem rather than a one-size-fits-all surgery decision; strongest on diagnostic strategy and MRI-first pathways, more conservative when discussing alternative or integrative approaches outside the conventional clinical evidence base.
What this does not prove: That every man should be screened with PSA. Trial data shows benefit at the population level over many years, but with significant overdiagnosis and overtreatment trade-offs that the individual must weigh.
What this is not a guarantee of: That MRI before biopsy will catch every clinically significant tumor, or that active surveillance will be appropriate for every early-stage case. Outcomes vary by age, tumor grade, family history, and individual risk profile.
What this should not replace: A face-to-face conversation with a GP and, where appropriate, a urologist who knows your case. This does not mean you should change or stop your current treatment or screening plan on your own.
What to know about the source: The host has commercial affiliations with two health-tech companies (LOAM Science, Throne Science) that do not relate to the prostate cancer content of this episode but are worth knowing about when watching the show generally. The guest specialist is involved in active research on prostate cancer screening pathways, which is the lens through which he discusses screening trial design.
What survives the uncertainty: That prostate cancer is increasingly a personalized decision involving age, risk, tumor characteristics, and patient priorities, and that the choice between active surveillance and treatment is now a real choice rather than an automatic one.
Where people go wrong
- Treating a single elevated PSA as a cancer diagnosis without further evaluation, or skipping the GP conversation about what to do with an abnormal result.May lead to unnecessary anxiety, unnecessary biopsies, or rushed treatment decisions for slow-growing cancer that may not need immediate action.
- Avoiding the prostate health conversation altogether due to discomfort with the topic or fear of a finger exam.May delay diagnosis until the disease has advanced, especially in higher-risk groups where outcomes worsen significantly with later diagnosis.
What to expect over time
- GP conversationDiscuss prostate health with your GP from age 45 to 50, earlier if you have family history or above-average ethnic risk. Decide together whether to do a PSA test now and what the plan is if the result is elevated. Keep a copy of your baseline PSA for future comparison.
- If PSA is elevatedRepeat the PSA after a few weeks if appropriate, avoiding cycling, ejaculation, or any infection in the days before the retest. If the elevation persists or is high to begin with, ask whether MRI should be the next step before biopsy. A specialist consultation usually follows within weeks.
- If a cancer is foundTake time to understand whether you have early-stage disease that could be safely monitored or whether treatment is recommended. Ask about active surveillance, focal therapy, nerve-sparing surgery, neuroSAFE techniques, and radiotherapy. A second opinion is appropriate for any treatment decision with significant side-effect implications.