Advances in cancer testing and medical imaging have created the potential for a new approach to cancer: watchful waiting. (Alfred pasieka/Science photo library/Getty Images)
A cancer diagnosis can trigger terror or an instinctive battle response. The urge to do something—anything—can be overpowering.
The urge to fight cancer aggressively fuels a multi-billion dollar industry in the United States. Millions undergo treatments with limited effectiveness, preferring action over the potentially more healthful option of “watchful waiting.”
This often overlooked approach involves careful monitoring of the patient’s condition without active treatment until it becomes necessary. It’s a strategic pause, grounded in evidence that some cancers, when caught early or found to be slow-growing, don’t require immediate intervention.
The watch-and-wait approach is advised for certain early-stage or slow-growing cancers for which immediate treatment doesn’t improve survival rates. This strategy is most common with prostate cancer but is also considered for breast, thyroid, and some blood cancers.
Watchful waiting reduces the toll of unnecessary cancer treatments, both financially and in terms of patient suffering. While few currently choose this less-invasive path, growing awareness of its benefits is gradually making its way into clinical practice and cancer strategies focused more on the patient than the disease.
David Gay is one of the beneficiaries of this approach.
David Gay opted for watchful waiting when diagnosed with cancer. (Photo courtesy of David Gay)
In 2014, Mr. Gay faced his third biopsy results in the stark silence of a urologist’s office. He was poised for a fight, resolute in his preemptive decision: “If it’s cancer, it’s coming out,” he told The Epoch Times.
Yet, when confronted with the reality of his diagnosis, his perspective changed. Heeding his doctor’s counsel and with his family’s support, he chose not to rush into surgery or radiation but rather to opt for watchful waiting.
Mr. Gay’s decision reflects an emerging trend built on clearer insights about cancer prognosis and research that challenges the rush to conventional treatment.
The Watchful Waiting Approach
Active surveillance and watchful waiting offer personalized, conservative treatment paths.
While the terms are often used interchangeably, the American Cancer Society differentiates between “active surveillance” and “watchful waiting.” Active surveillance involves regular doctor visits, blood tests, and biopsies, while watchful waiting implies a more relaxed follow-up based on symptoms.
“One of the reasons to think about active surveillance and delaying treatment is to prevent side effects, which almost always accompany treatment for cancer, including problems related to surgery,” writes Stanford oncologist Dr. Lidia Schapira for the American Society of Clinical Oncology.
Cancer treatment often comes with a significant toll on the body that must be measured against the actual risk that the cancer presents, experts say. (Justin Paget/Getty Images)
Reflecting a growing acceptance of less aggressive treatment options, active surveillance has more than doubled in U.S. urology practices for prostate cancer, rising to 59.6 percent in 2021 from 26.5 percent in 2014.
The number of people opting for active surveillance to treat low-risk prostate cancer has increased significantly in the past decade. (Source: Time Trends and Variation in the Use of Active Surveillance for Management of Low-risk Prostate Cancer in the US, JAMA Network Open, 2023)
A 2012 study published by The New England Journal of Medicine reported no significant survival difference after 12 years between men with early-stage prostate cancer who underwent surgery and those who opted for watchful waiting.
“Absolute differences in mortality between the study groups were less than 3 percentage points,” wrote the authors, adding that a subgroup of men with higher prostate-specific antigen (PSA) values or higher-risk tumors may have benefited from surgery.
More recent findings suggest that even if a cancer progresses during active surveillance, that doesn’t decrease the high survival rate. The study found that 97 percent of men with localized prostate cancer survive for at least 15 years, irrespective of treatment. However, researchers pointed out that side effects impacting urinary and sexual function in those opting for treatment could persist for more than a decade.
As diagnostics and treatments improve, Dr. Schapira envisions cancer becoming manageable. “With better and more precise treatments, we will face a growing number of individuals whose cancer becomes a ‘chronic disease,’” she told The Epoch Times. In other words, it’s something that people live with rather than wage war against.
Innovations such as circulating tumor DNA (ctDNA) detection are paving the way for active surveillance to become a more prevalent option in managing solid tumors, Dr. Nathan Goodyear, an integrative health physician specializing in oncology, said in an interview with The Epoch Times. CtDNA is DNA from cancerous cells that have died and broken off from the tumor, circulating in the blood. Testing for ctDNA can let doctors detect and diagnose cancer and provide insight into treatments, as well as tell whether a given tumor is growing or shrinking. These advanced detection methods could lead patients to choose to take a more passive stance toward their cancer, he said.
(Illustration by The Epoch Times, Shutterstock)
However, even with effective detection methods, some people may prefer to get their cancer treated. According to Dr. Goodyear, the watchful waiting approach to cancer treatment is a nuanced choice that may not suit every patient.
“Watchful waiting is not for all cancer patients, just as ‘shock and awe’ treatment campaigns are not for all cancer patients,” he said.
The appropriateness of this method should be carefully considered through thorough evaluation and candid conversations based on realistic expectations, potential risks, and the benefits it offers, Dr. Goodyear said.
Proactive Strategies in Watchful Waiting
Contrary to perceptions of passivity, Dr. Goodyear defines watchful waiting as a proactive, health-centric approach distinct from conventional treatments.
“Watchful waiting by no means implies nontreatment. The concept only applies to the conventional strategy of surgery, chemotherapy, radiation, and conventional immunotherapy,” he explained.
Nutrition is a cornerstone of this strategy, as Dr. Goodyear noted its importance in strengthening the immune system and engaging the body’s defenses against cancer. Equally vital are lifestyle modifications such as regular exercise, stress management, restorative sleep, and nurturing relationships, which collectively form a comprehensive support system for cancer patients, regardless of treatment protocol.
It’s worth noting that the body is actively removing problem cells and cancer cells, but this mechanism can break down, letting cancer cells grow. This problem can be exacerbated by lifestyle choices such as smoking or eating a diet high in added sugars.
The 2021 Exercise During Active Surveillance for Prostate Cancer (ERASE) Trial, focusing on men with non-metastatic prostate cancer under active surveillance, reinforced the value of lifestyle changes in cancer care. The study found that high-intensity exercise significantly reduced PSA levels, a primary indicator of prostate cancer. The slower increase in PSA levels among participants suggests that regular exercise might slow the progression of the disease.
In addition to these physical benefits, the approach of “letting go,” a pivotal aspect of watchful waiting, plays a crucial role in the healing process. In relinquishing the urge for immediate aggressive medical intervention, patients allow themselves time for reflection and consideration of all treatment options. Health care worker and patient experience has shown that this mental shift can be therapeutic, reducing anxiety and empowering patients to take control of their health journey.
Financial Toxicity of Cancer Treatment
Cancer care costs are projected to rise in the United States to more than $246 billion by 2030 from $183 billion in 2015. Key drivers include an aging population, increasing cancer cases, costlier treatments, and health care inflation.
These financial side effects also severely strain patients’ and families’ finances. Annual out-of-pocket costs, including copayments, deductibles, and uninsured treatments, total about $21 billion.
Cancer care costs per patient in the United States can be hefty, especially for uninsured individuals, ranging from $100,000 to $300,000 for treatments such as chemotherapy and surgery. The average expense is about $160,000.
Cancer care costs per patient in the United States can be hefty, ranging from $100,000 to $300,000 for treatments such as chemotherapy and surgery. (Illustration by The Epoch Times)
A survey by the American Cancer Society Cancer Action Network of more than 1,200 patients highlights cancer’s severe financial toll: Most were unprepared for the costs, leading to lifestyle changes and debt. More than half of the patients faced credit score impacts and debt collections, and many delayed care or chose cheaper treatments.
Adding to these financial challenges, a report by U.S. Rep. Katie Porter (D-Calif.) reveals a significant rise in cancer drug costs. The average price of new cancer drugs in the United States in 2021 was $283,000—up 53 percent from 2017. This escalation continues year after year.
Watchful waiting and active surveillance might ease cancer care’s financial strain. Although this aspect of these approaches is under-researched, early findings show promise in cost-effectiveness, particularly for prostate and thyroid cancers in older patients, by reducing the need for expensive treatments.
Debate continues over the pharmaceutical and health care industries’ promotion of aggressive treatments. The ongoing question is whether financial incentives influence treatment approaches.
Striking a Balance: Overtreatment in Cancer Care
Cancer care frequently involves overtreatment, a complex issue affecting both the quality of life and survival rates of patients. Studies show that many newly diagnosed individuals receive more aggressive treatment than necessary, which doesn’t significantly improve their chances of survival.
A study published in JAMA Surgery that focused on young adults with colon cancer found that they often received more intensive treatments than older adults, without corresponding survival benefits. The authors of this study note, “In the absence of clear superiority in treatment efficacy, a large proportion of young patients are being subjected to treatments with potential long-term toxicity.”
Moreover, research reveals a dangerous lack of patient awareness about the risks of cancer overdiagnosis and overtreatment, with less than 10 percent of those screened for cancer being informed about these risks despite a majority desiring this knowledge.
Physician bias and training contribute to their preference for aggressive treatments over less-invasive options. A 2021 article explores the tendency of oncologists to persist with aggressive treatments in advanced cancer cases, even when aware of the patient’s terminal status. This practice, known as “cancer overtreatment,” is influenced by a mix of expectations, fears, and the impulse to fight the disease.
“Cancer overtreatment cultivates the illusion that there are endless therapeutic solutions, which implies the omnipotence of medicine and immortality of the patient,” the authors reflect. This observation underscores the paradox wherein the relentless pursuit of treatment often overshadows the realistic outcomes of care, fostering a false sense of hope and deterring both patients and doctors from facing the reality of the illness.
Rethinking the Cancer ‘Battle’
Cancer carries an aura of menace unique among diseases for its prevalence and the grueling nature of its treatments—many of which require bombarding the body as well as the disease. Cancer care is often equated with warfare.
Dr. Goodyear criticized conventional training for its “shock and awe” cancer treatment strategy, which favors swift, aggressive action. This combative approach can heighten fear, influencing patient attitudes toward the disease, he said.
“It doesn’t help at all that we have embedded communication about cancer in war rhetoric, and that the language about cancer is about putting up a good fight,” Dr. Schapira told The Epoch Times. This entrenched association between cancer and warfare makes the suggestion of inaction, or watchful waiting, seem not only odd but contrary to a patient’s instincts, she said.
Researchers have documented that oncologists will often persist with aggressive treatments even when they're aware that the patient has terminal cancer. (Justin Sullivan/Getty Images)
Research illustrates that labeling a condition as “cancer” can bias patients toward unnecessary surgery, even when the risk is minimal and the survival rate without intervention is high.
A 2019 study presented participants with a scenario: the discovery of a low-risk nodule in their thyroid gland. When labeled as cancer, many opted for surgery despite the risks and a 99 percent survival probability without intervention.
Such findings underscore the excessive anxiety that a cancer label can provoke, leading to hasty decisions for treatment—whereas a wait-and-see approach may be more prudent and less invasive.
Voices of Patients Navigating Cancer With Watchful Waiting
For Mr. Gay, active surveillance is about resilience. Routine blood tests and PET (positron emission tomography) scans serve as anchors, providing a structured approach to managing the psychological weight of a cancer diagnosis. Choosing this path has also allowed him to seek second opinions before taking action.
Despite the presence of cancer, he finds solace in the support of his family and men’s groups.
“Over time, the mental side of knowing you are walking around with cancer takes a back seat,” he said.
Parallel to Mr. Gay’s journey is the story of Augie, whose brain tumor was discovered at age 8. His family faced a daunting choice but chose to watch and wait, bolstered by their insurance’s coverage for the frequent MRIs required to monitor his tumor size.
Augie in August 2023. (Emily Frazier Williams)
The family’s decision to avoid immediate treatment for Augie’s asymptomatic tumor was shaped by the risks of both chemotherapy and surgery.
“Chemo has awful side effects, so I couldn’t understand why we would choose it absent any statistical benefit in treatment,” Emily Frazier Williams, Augie’s mom, told The Epoch Times.
They also deliberated over the life-threatening and brain-damaging risks of surgery, leading them to a cautious health management approach.
“It was very disconcerting at first to know he had cancer and we were doing nothing, but focusing on being as non-invasive as possible was such a help,” Ms. Williams said.
The family understood from a medical standpoint that by choosing to wait, they could potentially avoid the risk of a traumatic brain injury, a known risk associated with the proposed brain surgery. Medical professionals advised them that undergoing surgery during adolescence could be more advantageous, as the brain’s plasticity at this stage aids in recovery. Additionally, being older, Augie would be more capable of articulating any changes or symptoms that he experienced.
After years of opting for watchful waiting for their son Augie’s cancer, the family faced a turning point when significant tumor growth necessitated surgery at age 12.
Despite the eventual need for surgery, the family values their initial decision, which allowed Augie a normal childhood and the opportunity to mature, enabling him to engage more actively in his health care decisions.
“Augie had a much better understanding as he got older, so he could advocate and make his own choices about care,” his mom said.
Reflecting on their journey, Ms. Williams expressed gratitude for the chosen path. “I am so glad that we took the approach we did; it minimized the health impact to my son,” she said.
Augie, now 16, is considered cured. Ms. Williams shared her hope that Augie’s positive outcome will encourage more doctors to consider a hands-off treatment approach for other families.
Redefining Victory in Cancer Care
The power of inaction, or the art of “doing nothing,” is garnering attention for its role in the healing process. This concept, often seen as counterintuitive in a society that values quick fixes and immediate results, embraces the idea of surrender—not as giving up, but as a strategic choice.
Surrendering to the natural course of a condition—especially in cases where medical interventions may not offer a clear advantage—reflects a broader shift toward patient empowerment in health care. More patients are delaying aggressive cancer treatments and making lifestyle choices such as eating better and reducing stress to better support the body’s inherent capacity for self-regulation and healing.
David Gay says his decision to opt for watchful waiting over cancer treatment has let him maintain daily routines and keep his quality of life. (David Gay)
Mr. Gay’s story serves as an example. Several years into his journey of watchful waiting, his quality of life remains at the heart of his treatment philosophy. By forgoing immediate, aggressive treatment, Mr. Gay has maintained his daily routines and well-being—as well as a quality of life that may have suffered because of side effects from cancer treatment.
A New Era in Cancer Treatment
While some cancers do require immediate treatment, with worsening outcomes as treatment is delayed, many others don’t. Fortunately, researchers are giving us a clearer picture of which is which. These insights give patients greater choice and make their preferences as pivotal as the oncologist’s expertise.
This shift is long overdue, according to experts such as Dr. Goodyear. “The center of the wheel for cancer care is supposed to be the patient,” he told The Epoch Times.
The medical team’s role is to guide, inform, and respect the patient’s wishes, presenting all options without bias, Dr. Goodyear said. The true decision-makers are the patients themselves, with the medical team serving as their advisers and advocates.
Dr. Schapira has some advice for those torn between immediate action and watchful waiting: Immerse yourself in understanding your diagnosis, cultivate a team approach with your oncologists, and seek psychological support to alleviate anxiety. This approach enables patients to better tailor their treatment to align with their convictions.
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