Review of ASPI’s ‘The Pathway’: Navigating Prostate Cancer Without Losing the Road

Register for the May ASPI webinar on living with low-risk PCa featuring Dr. Adam Weiner

(Editor’s note: One of the high-priority goals of Bill Manning, the executive director of Active Surveillance Patients International, has been to develop a free, downloadable book to help men who are newly diagnosed with low-risk prostate cancer, often a source of panic and a rush to unnecessary treatments with potentially serious life-changing side effects. Manning and ASPI have produced a compact ebook filled with hard-earned wisdom and practical advice, vetted by and inspired by a couple of the top experts in the field. Manning and Richelle Laturnus, ASPI’s executive assistant, co-authored The Pathway, which is available for downloads or online reading at https://aspatients.org/the-pathway-active-surveillance-guide/ It goes live today, May. 1.

(Following is my book review and an interview with Manning.)

By Howard Wolinsky

Reading The Pathway: Your Guide to Active Surveillance, I kept thinking about the man who has just been told he has prostate cancer and feels the floor give way beneath him. He hears the word “cancer,” and everything speeds up — the fear, the uncertainty, the urge to do something immediately. I’ve heard this and experienced it.

What this free ASPI ebook does so well is slow that moment down. It tells the reader, in effect, take a breath. Not all prostate cancers are dangerous, and virtually no diagnosis demands a rush to treatment.

Full disclosure: I am a co-founder of ASPI, the patient-led organization behind this 42-page ebook. That gives me a close view of the philosophy behind it, but it also lets me say with confidence that The Pathway is a well-written guide, filled with wisdom and practical advice for men who are just beginning the path after an early diagnosis of low-risk prostate cancer. It was created for newbies — men who suddenly find themselves in a bewildering new world of test results, jargon, fear, and too many choices all arriving at once. But anyone, who has been on this trail for a while, would benefit from reading this book.

The book is informative and reassuring without being naïve. It does not minimize the shock of diagnosis, but it does try to separate fear from fact. One of its most important messages is that if your cancer is “low-grade, low-risk, localized, early, or favorable risk,” then Active Surveillance is a real option — “a plan to monitor your cancer safely without rushing into potentially unnecessary treatment.”

Too many men are not given the full menu of choices, In the US, 40% of men still opt to be treated—their choice of course—compared to 94% when I was diagnosed in 2010, but lagging behind the 5-10% uptake in places like Sweden, UK, and the state of Michigan.

What I especially like is that the book does not come across as anti-treatment. It does not push ideology. It pushes understanding. ASPI’s philosophy is not to oppose treatment but to ensure men know that Active Surveillance is also an option for some, and that any decision should be informed, thoughtful, and grounded in both medical evidence and quality-of-life considerations.

That balance comes through clearly in the line: “Our goal is simple: to help you make an informed and confident choice about your health. Your decision should balance treating your cancer, if necessary, with protecting your quality of life for as long as possible.”

The ebook also recognizes something that newly diagnosed men often need to hear several times before it really sinks in: Active Surveillance is not the same as doing nothing. The book says this plainly and effectively: “Active Surveillance is not ‘doing nothing.’ It means keeping a close eye on your cancer with regular tests and acting if things change.” That is a crucial message, because many men still hear “surveillance” and think neglect or passivity, when in fact it is a careful, structured approach to care.

I was also struck by how much of the book is about options. That may be one of its most helpful gifts to readers. Men who are new to prostate cancer are suddenly hit with an avalanche of unfamiliar terms and decisions: pre-biopsy MRI, biparametric MRI, targeted biopsy, systematic biopsy, transperineal versus transrectal biopsy, PSA density, micro-ultrasound, pathology review, and second opinions. Whew!

For someone just entering this territory, it can be mind-boggling. This book understands that and tries to guide the reader through it step by step, often with summary charts and flow diagrams that make the information easier to absorb.

And those visuals matter. The book is chock-full of useful graphics and flowcharts that map the complicated pathways of diagnosis and follow-up. That is not just good design. It is good teaching. Prostate cancer decision-making can feel abstract and chaotic when reduced to text alone, but the charts help impose order and show readers where they are, what comes next, and what the alternatives may be.

The sections on imaging and biopsy are especially timely. The book reflects many of the important changes that have reshaped Active Surveillance in recent years, including the growing role of pre-biopsy MRI, targeted biopsy, biparametric MRI, and increasing attention to micro-ultrasound. None of these options were available when I got on the AS trail nearly 16 years ago.

The ebook particularly does a good job of explaining newer options in language a patient can understand, including the appeal of bpMRI for men who want to avoid contrast dye or may be anxious about the experience and that micro-ultrasound is a less expensive and quicker alternative to MRIs.

The discussion of PSA density is especially strong. Too many men still get hung up on PSA alone, and the ebook makes the more useful point that PSA only really means something in context. It reminds readers that “a high PSA doesn’t always mean cancer, and a normal PSA doesn’t guarantee no cancer,” while stressing the importance of prostate size, MRI findings, family history, and especially PSA density. That is thoughtful, modern, and practical advice.

[By the way, leading proponents of AS inspired and vetted the book. So that’s some extra reassurance: Dr. Laurence Klotz, of the University of Toronto, an AS pioneer; Dr. Matthew Cooperberg, of the University of California, San Francisco, a strong AS advocate, and Dr, Mark Scholz, of Prostate Cancer Research Institute, who helped mainstream AS in his medical oncology practice and in the 2010 book, Invasion of the Prostate Snatchers: An Essential Guide to Managing Prostate Cancer for Patients and Their Families.

I also appreciated the line: “You do not need to make every decision today. Start by gathering your results, writing down your questions, and learning about your options.” For a frightened man who wants to get that damn cancer out immediately, that advice can be invaluable. The book seems designed to muffle panic just enough to let reason back into the room

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The ebook mentions—more in passing—exercise and diet. When I was diagnosed in 2010, I asked about them and got no direction. Now, a lot more is known. An additional chapter on diet, exercise, sleep, and other lifestyle issues would make sense if the book is updated.

The ebook looks ahead. It touches on emerging issues such as a biopsy-free future in Active Surveillance, and the potential role of PSMA PET/CT imaging, while still recognizing that some of these approaches remain promising rather than standard. That gives the guide a current, forward-looking feel without overselling what medicine cannot yet fully deliver.

I question the book’s statement that “most men on Active Surveillance never need treatment.” Active Surveillance is strongly supported for many men with low-risk disease, and many do avoid or defer treatment for years for the rest of their lives. But many depart AS fopr a variety of reasons—disease progression and emotional distress— within five to 10 years after initial diagnosis. I call thie AS’s “dirty little secret.”

Outcomes vary across studies, and some published data suggest that a substantial share (50% or higher) of men eventually go on to treatment over time, so the safer phrasing may be that many men can delay or avoid treatment for long periods while preserving quality of life.

Still, that caveat does not diminish the The Pathway’s overall achievement. Congratulations to Bill Manning, ASPI’s executive director and a long-time AS patient, and Richelle Laturnus, assistant director, for a job well done.

The Pathway is thoughtful, compassionate, and deeply useful. It is well-written, full of hard-won wisdom, and rich in practical advice for men just starting down the path of early diagnosis of low-risk prostate cancer. Most of all, it helps readers understand that they have choices, that they do not have to make every decision in a panic, and that Active Surveillance is not surrender but a deliberate form of care.

In the end, what makes The Pathway valuable is not just the information, though there is plenty of that. It is the feeling the book gives the reader: that there is a path through the confusion, that he does not have to make every decision in one terrified afternoon, and that surveillance is not inaction. For a man newly diagnosed with low-risk prostate cancer, that may be the most important piece of wisdom of all.

This is a must-read for those who are newly diagnosed with low-risk and considering AS and for those who want a refresher on the current pathway to AS and what’s ahead on the road.

ASPI’s first ebook: A roadmap for Active Surveillance

By Howard Wolinsky, Editor, The Active Surveillor

ASPI’s new e-book, The Pathway, was designed to help men navigate the decisions around Active Surveillance. Bill Manning, ASPI’s executive director and co-author of the book, says the idea began with a simple goal: turn a confusing medical process into a clear flowchart patients could actually use.

In this edited Q&A, Manning explains why he created The Pathway, who he hopes will read it, and how the book’s visual structure grew out of his original rough charts and was shaped into final form by assistant director Richelle Laturnus.

Since stepping into a larger leadership role at ASPI in 2024, Manning, 73 of the San Diego area, who has been on AS since 2009, has pushed several practical patient-education ideas, including the new e-book, short one-minute answers for patients extracted for ASPI’s 1 1/2-hour webinars, many website refinements and a relaxation page built from video he shot in Hawaii and set to music by his friend Jim Kimo West, a Hawaiian slack-key guitarist and Weird Al Yankovic’s longtime lead guitarist.

In this conversation, Manning says The Pathway grew out of a desire to give men a usable map through the many crossroads of prostate-cancer decision-making, whether they are newly diagnosed or already years into surveillance.

Q&A

The Active Surveillor (TAS): Why did you create The Pathway?
Bill Manning: “One of my large initial motivations in making it was to create an Active Surveillance flow chart. It was at least 3 years ago I threw out the idea of the e-book to the ASPI board, but it didn’t really get into gear until about 2 years ago.

TAS: Who did you have in mind as the reader?
Manning: The average guy on the street … He may have recently got a diagnosis, but it may not have been categorized as low risk. And it’s our job to let him know it exists and what it means.

TAS: This is not just for newly diagnosed men?
Bill Manning: I don’t want to exclude anybody. There may be a guy who’s been on AS for 3 years, or even 5 years. There’s been a lot of changes in the last 5 years, and he’s wondering, ‘Oh, no, my PSA just went up 2 points! Is it time for surgery?’ This book would hopefully equip him with everything he needs to decide whether that’s a good idea.

TAS: The charts are one of the most distinctive parts of the book. How do they work?
Bill Manning: They’re designed to be sequential. If you get to the point where everything’s focusing on AS, then you can stop. And that’s that. But if more questions go unanswered, you have a way to find the right questions to ask. That’s the goal here.

TAS: How did those charts come together?
Manning: I started off with a rough outline. I asked a couple of associates for input, and then Richelle took it over. She basically lassoed the whole thing and pulled it into the form it is now, based on my initial work.

TAS: What do you want readers to take away from it?
Bill Manning: I would like them to walk away armed with enough knowledge that they can make an informed decision.

TAS: Are you trying to push men away from treatment?
Bill Manning: Our goal is not anti-treatment, but anti-unnecessary treatment. Even for those who can be on Active Surveillance, but decide to stop, not because of the anxiety or family pressure or whatever reason, and they go ahead with treatment, at least they have had the opportunity to have this knowledge presented to them, so they can make an informed decision. That’s the goal.

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ASPI to Host Dr. Adam B. Weiner on Living Well With Active Surveillance

On Saturday, May 23, 2026, at noon Eastern, Active Surveillance Patients International will host Adam B. Weiner, MD, a urologist at Cedars-Sinai for a program titled, “Living Well on Active Surveillance: What Matters Most (and What Doesn’t).”

REGISTER HERE: https://zoom.us/meeting/register/VfFFjirZSbyHoc8cNIMZJQ#/registration

For men on Active Surveillance, one of the continuing challenges is separating what truly deserves attention from what may only add anxiety. Weiner will discuss the key components of Active Surveillance, what patients can do to optimize their monitoring, and what is currently known about the role of diet, exercise, and supplements in prostate cancer care.

He will also address the uncertainty that can accompany Active Surveillance and offer practical guidance on what matters most — and what may not warrant as much worry.

Questions are welcome. Patients may submit them in advance to contactus@aspatients.org. There will also be a dedicated time for live Q&A following the presentation