Treatment of stage A1 prostate cancer: the case for observation

Stage A1 prostate cancer implies indolence. If only well-differentiated low-volume tumors are considered, the rate of cancer growth, clinical progression, and prostate cancer death is exceedingly low. All but a very few of these patients will need observation alone. Younger patients (those less than 60 years of age) and those with more moderately differentiated tumors or with serological or ultrasound evidence of residual cancer need further evaluation. It is likely that patients within this group are those who have in past studies experienced a higher degree of progression and cancer mortality. A stepped-up effort to detect nonpalpable prostate cancer has included PSA and transrectal ultrasound with random biopsies. Prostate cancer screening using a serum test and/or ultrasound has allowed increased detection of otherwise clinically silent cancer (stage A). Occult prostate cancer identified by needle biopsy or detected through elevated PSA levels most often is peripheral zone cancer and more aggressive than that arising in the transitional zone. A reclassification of stage A is therefore needed and a new scheme for TNM staging was recently introduced (Table 4). Because of its more aggressive potential, the new stage T1c will likely require different treatment recommendations than those for traditional stage A1 (T1a). More time and evaluation will be needed to estimate the prognosis of those diagnosed with minimal stage T1c prostate cancer.