Contemporary management of patients with T1a and T1b prostate cancer

Incidental prostate cancer (PCa) - T1a to T1b - still represents a non-negligible clinical entity requiring good decision-making skills to correctly manage patients, most of whom may have insignificant tumours. The aim of the current review is to summarize the available evidence-based information that may be helpful in daily clinical practice.

Although having major clinical implications, the current TNM staging system for incidental PCa has not been re-evaluated for 20 years. Recently, many reports questioned the accuracy of T1a-T1b classification and strengthened the fact that the decisions to offer further treatment in cases of incidental cancer should be based upon the estimated probability of clinical progression compared to the relative risk of therapy and potential benefit to survival. The use of prostate-specific antigen (PSA) levels before and after transurethral resection of the prostate (TURP) and Gleason score at diagnosis may help in estimating the need for further therapy.

Active surveillance should be recommended for well differentiated incidental cancers in patients with limited life expectancy and low PSA levels after TURP or, alternatively, in patients who are uncomfortable with potential treatment-related complications. In patients with a longer life expectancy - especially for poorly differentiated tumours - radical prostatectomy should be considered. PSA levels before and after TURP increase the accuracy in estimating the need for active management. Further studies focusing on biologic and clinical markers of progression are mandatory to identify those patients who require active treatment after incidental PCa diagnosis.