‘Dark Knight’ Star Colin McFarlane, 65, on Choosing Active Surveillance to Treat His Prostate Cancer – Here’s What That Treatment Approach Looks Like

McFarlane was diagnosed with low-risk prostate cancer after a routine PSA test, and rather than surgery or radiation, his doctors recommended active surveillance.

“[Men usually] don’t go to the doctor unless they’re in pain,” McFarlane said, U.K.-based outlet The Mirror reported.

“It’s a silent killer, but it can be monitored and treated. A simple blood test could save lives.”

His openness has made him a rare public voice for a treatment path that even doctors say is widely misunderstood.

Active surveillance is often mistaken for doing nothing, but that couldn’t be further from the truth, according to Dr. Andrew G. Winer, a urologic oncologist at NYC Health + Hospitals/Woodhull.

“The biggest misconception is that active surveillance means doing nothing,” Dr. Winer tells SurvivorNet.

“In reality, active surveillance is an active treatment strategy in its own right.”

For patients like McFarlane, that means a structured routine: PSA blood tests every three to six months, prostate exams roughly every six to twelve months, an MRI every one to two years, and a repeat biopsy typically within the first year, then every two to three years after that.

If the cancer ever does show signs of progressing — a higher Gleason grade, a growing tumor on MRI, a consistent rise in PSA — that’s not a sign the plan failed.

“Moving from active surveillance to treatment is not a failure of the surveillance program,” Dr. Winer says.

“It means the monitoring worked.” For McFarlane and the men willing to speak publicly about choosing to watch and wait, that reframing may be exactly what more patients need to hear.

What a Typical Schedule Looks Like

Active surveillance follows a clear, structured calendar of check-ins and tests.

While the exact schedule is tailored to each individual — based on age, overall health, and the specific characteristics of the cancer — Dr. Winer describes a general framework that most patients can expect:

• PSA blood test. PSA (prostate-specific antigen) is a protein produced by the prostate that can rise when cancer is present or growing. This blood test is typically done every 3 to 6 months at first, then at least every 6 months once results have been stable for a while.
• Doctor’s visit and prostate exam. Appointments happen roughly every 6 to 12 months and may include a digital rectal exam (DRE), in which a doctor gently examines the prostate through the rectum to check for changes in size or texture. Whether a DRE is performed depends on your individual risk profile and monitoring plan.
• Prostate MRI. Magnetic resonance imaging gives doctors a detailed picture of the prostate and can detect changes that might not show up in blood tests. This is often done every one to two years, though some programs space these out further if prior scans have been consistently stable.
• Repeat biopsy. A biopsy — in which a small sample of prostate tissue is examined under a microscope — is typically recommended within the first year of starting active surveillance to confirm the cancer’s characteristics. After that, biopsies are usually repeated approximately every two to three years, or sooner if something concerning appears.

At every visit, Dr. Winer and his team review the PSA trend over time, ask about any urinary or other symptoms, and decide whether additional testing is needed.

WATCH: Active Surveillance for Low Risk Prostate Cancer

He stresses one reassurance that patients often need to hear: “One abnormal PSA does not automatically mean the cancer is progressing. PSA can fluctuate for many reasons, so we often repeat the test before making any decisions.”

What Would Actually Trigger a Move to Treatment?

This is often the question patients most want answered: “When would this change?”

Dr. Winer is clear that the decision to move from active surveillance to a more active and aggressive treatment is not made lightly, and it is never based on a single data point.

The most important trigger is evidence that the cancer itself has become more aggressive, not just that one number went up.

Specific findings that would raise concern include:

• A biopsy showing a higher Gleason grade — these are scoring systems pathologists use to describe how abnormal cancer cells look under a microscope, with higher scores indicating more aggressive behavior
• A significant increase in the amount of cancer detected in the prostate
• Consistent or substantial changes on MRI suggesting the tumor is growing or becoming more concerning
• Repeatedly rising PSA levels, particularly when supported by other findings
• A new abnormality felt during a prostate exam

Importantly, a change in PSA or MRI findings typically prompts further evaluation — often a repeat PSA, a new MRI, and possibly a biopsy — before any treatment recommendation is made.

Guidelines from major oncology organizations generally recommend confirming cancer progression with a biopsy before switching to definitive treatment.
So, what if surveillance eventually leads to treatment?
“Moving from active surveillance to treatment is not a failure of the surveillance program — it means the monitoring worked,” Dr. Winer says.

What Factors Go Into Treatment Choices?

For many patients, the differences between treatment options — such as surgery, radiation, or hormone therapy — can be subtle. But those nuances matter, especially when side effects impact daily life.

Dr. James Ryan Mark, a urologic oncologist at Fox Chase, urges patients to weigh the benefits and trade-offs of each treatment option carefully.

“In certain cases, the differences in treatment options can be relatively minor,” Dr. Mark explains.

WATCH: Balancing Treatment and Quality of Life: What Men Should Know About Prostate Cancer Care

One common combination for aggressive prostate cancer is radiation therapy paired with androgen deprivation therapy (ADT), also called hormone therapy, which suppresses testosterone to slow cancer growth. While this approach can significantly improve recurrence rates and survival, it’s not without cost — especially for older patients.

“Adding those treatments to radiation has a big improvement on the recurrence rate of survival,” Dr. Mark says. “But not all men sustain that big of an improvement, and particularly if you’re older, taking out your testosterone can really affect your muscle strength and vitality.”

For some, preserving strength and energy may outweigh a modest increase in cancer control.

“As patients are getting elderly, to some, that is more important than maybe a 10% [increase] in their case of prostate cancer control,” he adds.

Dr. Mark also cautions against rigid treatment protocols that don’t account for individual needs. He encourages patients to ask their care team questions and explore different types of treatments, specifically inquiring about possible treatment outcomes and the side effects they bring.

“Sometimes, it almost seems dogmatic in the way the treatments are delivered,” he says. “It’s always good to ask what the benefit of each aspect of the treatment is and what can be given in a different way.”

Dr. Vivek Narayan, a medical oncologist at the University of Pennsylvania, is part of a growing movement in oncology that embraces combination therapy as the backbone of metastatic prostate cancer treatment. This approach pairs traditional hormone therapy (also called androgen deprivation therapy or ADT) with FDA-approved oral agents like abiraterone, enzalutamide, apalutamide, and darolutamide — each designed to disrupt the testosterone-driven growth of cancer cells further.

WATCH: A Message Of Hope For Men Fighting Advanced Prostate Cancer

These therapies not only slow disease progression but also offer patients a chance at living longer, fuller lives — even with an advanced diagnosis.

Dr. Narayan highlights the progress in advanced prostate cancer care, noting that the disease is increasingly manageable and patients now have greater potential for improved quality of life. Still, patients must be carefully monitored.

“Even with metastatic prostate cancer, it’s not always the cancer that causes the biggest problems. We’ve got to keep an eye on overall health, because that matters just as much.” Dr. Narayan notes.

This shift in perspective is critical — not just for patients, but for caregivers and clinicians alike. It reframes the diagnosis from a terminal sentence to a chronic condition that can be managed with precision and care.

The outlook for prostate cancer care is promising, driven by breakthroughs in treatment and the rise of personalized medicine. Dr. Narayan’s work at Penn Medicine, among other cancer research centers across the country, continues to push the boundaries of what’s possible, offering patients not just treatment but a renewed sense of continued hope.

Prostate Cancer Screening and Warning Signs

When you do get screened for prostate cancer, your doctor will run a few tests.

One of the tests is the PSA test, a simple blood test that screens for prostate cancer. It looks for higher levels of prostate-specific antigen (PSA) in the blood. An elevated PSA test does not always mean you have prostate cancer. It could also reflect that your prostate is enlarged, which is common, or it could signal an infection or inflammation.

Your doctor may also conduct a digital rectal exam (DRE) to check your prostate for lumps.

Depending on the results of these tests, imaging scans and a biopsy may be ordered.

WATCH: How Gleason Grade Determines Treatment

Prostate cancer does not always behave the same in every man it impacts. The cancer can be considered “low-risk” and can be slow-growing, and treatment might not be necessary. In other men, the cancer may grow faster or more aggressively, requiring more immediate treatment. Because of this, there is some debate about screening.

The United States Preventive Services Task Force recommends that men at average risk between the ages of 55 and 69 years talk with their doctor about the pros and cons of prostate cancer screening.

The American Cancer Society recommends that men at age 50 who are at average risk should begin screening. Men who are at high risk of prostate cancer should begin screening at age 40. Men with a close relative diagnosed with prostate cancer should consider annual screenings in their 30s.

SurvivorNet experts suggested that men consider factors like their family history, genes, and age when deciding whether and when to screen.

Symptoms of prostate cancer may include:

• Urinating more often
• Waking up in the middle of the night to pee
• Blood in your urine
• Trouble getting an erection
• Pain or burning when you urinate
• Pain in your back, hips, thighs, or other bones
• Unexplained weight loss
• Fatigue

Questions for Your Doctor

If you have experienced symptoms associated with prostate cancer or have a screening coming up, here are some questions you may ask your doctor:

• If I have elevated PSA levels, what could be causing that besides cancer?
• How long will it take to learn if my PSA levels warrant further testing?
• What are the treatment options that are best suited for me based on my risk level?
• What financial resources exist to help me with the costs associated with treatment?
• How long will my potential treatment prevent me from working or continuing normal activities?

Learn more about SurvivorNet's rigorous medical review process.

---