On a recent episode of Grey’s Anatomy, longtime character Dr. Richard Webber faces a diagnosis that stops him in his tracks: prostate cancer. Instead of rushing into surgery, he chooses a strategy called watchful waiting. For someone used to saving lives in an operating room, the decision to wait feels counterintuitive. But it reflects a real medical conversation happening in clinics every day.
For many men, especially those diagnosed with slow-growing prostate cancer, the first treatment decision is not always surgery or radiation. Sometimes the plan is to monitor the cancer carefully while delaying aggressive treatment.1
For Black men, however, this decision can feel more complicated. Prostate cancer does not affect all men equally. Black men are diagnosed more often and die from the condition at significantly higher rates than other groups.2 In the United States, their mortality rate from prostate cancer is more than twice that of White men.2
Understanding how watchful waiting fits into a larger treatment strategy can help patients and families make informed decisions about care.
What Prostate Cancer Is and How It Develops
The prostate is a small gland located below the bladder and in front of the rectum. It produces fluid that helps carry sperm.3
Prostate cancer begins when cells in the prostate start growing out of control. In many cases, these tumors grow slowly and may never cause symptoms. In other cases, the cancer grows aggressively and spreads to nearby tissues or bones.3
Because prostate cancer often develops slowly, many men live for years without knowing they have it. Some cancers remain small and stable. Others eventually require treatment. This wide range of behavior is why doctors do not treat every prostate cancer the same way.3
What “Watchful Waiting” Means
Watchful waiting is a treatment approach where doctors monitor prostate cancer instead of treating it immediately.1
The goal is simple: avoid unnecessary treatment while still protecting the patient’s health.1
Some prostate cancers grow so slowly that the risks of surgery or radiation may outweigh the benefits.1 Treatments can cause side effects such as urinary incontinence, erectile dysfunction, and bowel problems.1 For certain patients, especially those with low-risk disease or older adults with other health conditions, careful monitoring can be the safest option.1
Watchful waiting is slightly different from active surveillance, which involves more frequent testing and biopsies. Watchful waiting generally involves fewer tests and focuses on treating symptoms if the cancer progresses.1
In other words, it is not ignoring cancer. It is monitoring it strategically.
How Doctors Decide Which Treatment Path to Recommend
When someone is diagnosed with prostate cancer, doctors do not jump straight to one treatment option. Instead, they go through several steps to understand the cancer and the patient’s overall health.
Step 1: Confirm the diagnosis
Most prostate cancers are first suspected through screening, not diagnosed right away. That distinction matters.
Doctors usually begin with screening tests such as a PSA blood test and a digital rectal exam (DRE). A PSA test measures the level of prostate-specific antigen in the blood. Higher PSA levels can be a warning sign, but they do not automatically mean cancer.4
PSA can also rise because of non-cancerous conditions such as an enlarged prostate, inflammation, or infection. A DRE can help a doctor feel for lumps, firmness, or other changes in the prostate, but it also cannot confirm cancer on its own.4
That is why a biopsy is so important. A prostate biopsy is the test that gives a definitive diagnosis.4 During a biopsy, small samples of tissue are taken from the prostate and examined under a microscope by a pathologist.4 This is the step that tells doctors whether cancer cells are actually present.4 The American Cancer Society is very direct about this: screening tests may raise concern, but the actual diagnosis of prostate cancer is made with a prostate biopsy.4
The biopsy does more than confirm whether cancer is there. It also helps show what kind of cancer it is and how aggressive it may be.4 If cancer is found, the tissue is graded, often using the Gleason score or Grade Group, which helps doctors estimate how quickly the cancer may grow and whether watchful waiting, active surveillance, surgery, or radiation makes the most sense.4
So in plain language, this first step works like this: screening raises the question, but biopsy answers it. And before anyone can responsibly recommend watchful waiting, active surveillance, or treatment, they need that answer.
Step 2: Determine how aggressive the cancer is
Once a biopsy confirms that cancer cells are present, the next question is just as important:
How likely is this cancer to grow, spread, or cause harm?
Not all prostate cancers behave the same way. Some grow so slowly that they may never threaten a person’s life. Others are more aggressive and need treatment sooner. That is why the biopsy is not just about finding cancer. It is also about helping doctors understand the cancer’s risk level.4
After the biopsy, a pathologist studies the tissue under a microscope and assigns a Gleason score or Grade Group.5 These tools describe how abnormal the cancer cells look compared with normal prostate cells.5 In general, the more abnormal the cells look, the more likely the cancer is to grow and spread. This grading process is a major part of deciding whether a patient is a good candidate for watchful waiting, active surveillance, or more immediate treatment.5
Doctors also look at other pieces of the puzzle, including the PSA level, how many biopsy samples contained cancer, and whether imaging shows anything concerning beyond the prostate.5 Together, these details help sort the cancer into categories such as low-risk, intermediate-risk, or high-risk disease.5
That risk level is what begins to shape the treatment conversation. A man with low-risk cancer may be offered watchful waiting or active surveillance, while a man with more aggressive disease may be advised to move more quickly toward surgery, radiation, or another treatment plan.5
In plain language, step 1 tells you whether cancer is there. Step 2 tells you how worried you need to be about it right now. That distinction is what keeps treatment decisions from being rushed, vague, or driven by fear alone.
Step 3: Stage the cancer (how far it has spread)
After the biopsy confirms cancer and Step 2 estimates how aggressive it looks, doctors need to answer one more big question: Is the cancer still contained in the prostate, or has it moved beyond it?
This is called staging. Staging is a standardized way clinicians describe how much cancer is in the body. For prostate cancer, the stage is based on several pieces of information working together: the biopsy results (including Grade Group), the PSA level, and sometimes imaging tests like MRI, CT, or bone scans if they’re needed.5
In plain terms, staging helps sort prostate cancer into categories like:
- Localized: cancer is only in the prostate.5
- Locally advanced: cancer has grown outside the prostate or into nearby structures.5
- Metastatic: cancer has spread to other parts of the body, often bones or lymph nodes.5
Doctors do not order every scan for every patient. Imaging depends on the person’s risk level. The reason this step matters is because the same cancer grade can lead to different treatment choices depending on whether the cancer is confined or has spread.
Self-advocacy language to use in this stage:
- “I want to understand my stage clearly. Is this cancer localized, locally advanced, or metastatic?”
- “Do I need imaging to check for spread, and if not, why not?”
- “Can you explain what my PSA and Grade Group suggest about whether it’s likely contained?”
Step 4: Look at the whole person (age, other conditions, and life expectancy)
Prostate cancer treatment decisions aren’t just about the tumor. They’re also about the person living with it.
Doctors consider age, overall health, other medical conditions, and estimated life expectancy, because the risks and benefits of treatment change depending on how long someone is expected to live and what else their body is managing. This is one of the reasons watchful waiting is sometimes recommended for people with significant other health conditions or a shorter life expectancy.4
This step is also where quality of life becomes central. Treatments like surgery or radiation can be lifesaving, but they can also affect urinary control, sexual function, and bowel function.4 So clinicians weigh whether immediate treatment meaningfully improves survival or whether careful monitoring is safer and protects day-to-day life.
Self-advocacy language to use in this stage:
- “I want us to weigh quality of life and long-term outcomes together.”
- “How do my other health conditions affect which options are safest for me?”
- “If we choose watchful waiting or active surveillance, what is the tradeoff we’re making, and what is the benefit?”
Step 5: Build a treatment strategy (and make the plan specific)
This is the step where everything comes together. The doctor uses your biopsy grade, PSA level, and stage, along with your health history and preferences, to recommend options. Major cancer resources list the main pathways as watchful waiting or active surveillance, surgery, radiation, and other systemic therapies depending on stage.4
Here’s the key point: watchful waiting only works when the monitoring plan is clear. It should never sound like, “We’ll just keep an eye on it,” with no details. A real plan includes what will be tracked, how often, and what triggers a switch to treatment.
Self-advocacy language to use in this stage:
- “Before I agree to watchful waiting, I want the monitoring schedule in writing. How often will I have PSA tests, exams, imaging, or repeat biopsies if needed?”
- “What exact changes would make us move from waiting to treating?”
- “Can you walk me through the top two options you’d recommend for someone with my risk level, and why?”
Why Early Detection Still Matters
Even when watchful waiting is part of the strategy, early detection remains one of the most important tools for survival.6
Prostate cancer often has no symptoms in its early stages. Screening tests help detect it before it spreads.6
A recent policy win in Alabama highlights the growing recognition of this need. Governor Kay Ivey signed legislation requiring insurance companies to cover prostate cancer screening at no cost for men at high risk.7 The bill, sponsored by Sen. Steve Livingston and Rep. Jeremy Gray honors Huntsville businessman and cancer survivor David McElhaney and AL.com columnist Roy S. Johnson.7 Under the law, insurers must cover screening for men over 50 at no cost.7 Covered procedures include:
- Prostate-specific antigen (PSA) blood tests
- Digital rectal examinations
Policies like this help remove cost barriers that often prevent early diagnosis. Early detection does not automatically mean immediate treatment. But it gives patients and doctors more options and more time to make informed decisions.
Call To Action: Building Knowledge Together
Understanding prostate cancer should never happen alone.
Inside the NOWINCLUDED community, members share knowledge about screening, diagnosis, and treatment decisions that affect Black families every day. From navigating PSA tests to understanding treatment options like watchful waiting, the goal is simple: make sure every person has the information they need to protect their health.
Open the NOWINCLUDED app, explore resources, and join conversations that help turn knowledge into prevention.
References
- ACS . (2023, November 22). Observation or Active Surveillance for Prostate Cancer. Retrieved from American Cancer Society: https://www.cancer.org/cancer/types/prostate-cancer/treating/watchful-waiting.html
- Lillard, J. W., Moses, K. A., Mahal, B. A., & George, D. J. (2022). Racial disparities in Black men with prostate cancer: A literature review. Cancer. doi:10.1002/cncr.34433
- ACS. (2023, November 22). What Is Prostate Cancer? Retrieved from American Cancer Society: https://www.cancer.org/cancer/types/prostate-cancer/about/what-is-prostate-cancer.html
- ACS. (2023, November 22). Initial Treatment of Prostate Cancer, by Stage and Risk Group. Retrieved from American Cancer Society: https://www.cancer.org/cancer/types/prostate-cancer/treating/by-stage.html
- ACS. (2025, March 21). Tests to Diagnose and Stage Prostate Cancer. Retrieved from American Cancer Society: https://www.cancer.org/cancer/types/prostate-cancer/detection-diagnosis-staging/how-diagnosed.html
- ACS. (2025, October 31). Can Prostate Cancer Be Found Early? Retrieved from American Cancer Society: https://www.cancer.org/cancer/types/prostate-cancer/detection-diagnosis-staging/detection.html
- Cason, M. (2026, February 25). Ivey signs into law no-cost prostate cancer screening bill named for AL.com’s Roy S. Johnson. Retrieved from AL.com: https://www.al.com/news/2026/02/ivey-signs-into-law-no-cost-prostate-cancer-screening-bill-named-for-alcoms-roy-s-johnson.html
