Key takeaways
- Prostate cancer staging relies on the TNM system, which assesses the tumor size, lymph node involvement, and metastasis (spread), along with PSA levels and Gleason score, to determine the extent of the cancer.
- The stage of prostate cancer significantly affects treatment decisions. Treatment options range from active surveillance in early stages to surgery, radiation, hormone blockade therapy, and chemotherapy in more advanced stages.
- Early detection of prostate cancer through regular screening is crucial, as the survival rate is very high when the cancer is diagnosed and treated in its initial stages.
Prostate cancer is the
Prostate cancer tends to progress slowly and less aggressively than many other types of cancer. If doctors diagnose prostate cancer in its early stages, the chances of survival are very high. In the United States, the 5-year survival rate for prostate cancer is
Prostate cancer can be classified into four stages, depending on how advanced it is.
In stage 1, the tumor affects only your prostate and has not spread to other tissues. In stage 4, the tumor has spread to tissues beyond your prostate and possibly to distant parts of your body.
In this article, we take a deeper look at the stages of prostate cancer and break down all the terms you’ll need to understand about these stages.
Cancer staging helps you and your doctor understand how advanced the cancer is and how much it has spread at the time of diagnosis. Knowing the stage of cancer also helps your doctor determine the best treatment options for you and estimate your chances of survival.
The most widely used staging system for cancer is the
“TNM” stands for:
- Tumor: the size and extent of the tumor
- Nodes: the number of nearby lymph nodes affected or the extent of lymph node involvement
- Metastasis: whether cancer has spread to distant sites in your body
Doctors use the TNM scale with many types of cancer. When using this system to determine the stage of prostate cancer, a doctor will also consider several other factors, including:
- prostate-specific antigen (PSA) levels
- Gleason prostate cancer score
- grade groups
PSA levels
PSA is a protein that’s made by both cancerous and noncancerous cells in your prostate. A higher PSA level in your blood is associated with an increased risk of developing prostate cancer. Many doctors will send you for further testing if your PSA levels are higher than 4 nanograms per milliliter (ng/mL).
According to the
Doctors commonly use PSA testing to screen for prostate cancer, although this approach is somewhat controversial. The American Urological Association currently offers the following guidelines on PSA screening:
- People at average risk of prostate cancer should have a baseline PSA test at 45 to 50 years of age.
- People with a family history or other risk factors for prostate cancer should have their baseline test earlier, at 40 to 45 years of age.
- After a baseline test, those who are 50 to 69 years old should be tested every 2 to 4 years.
Doctors also commonly perform a digital rectal exam, which involves using a gloved finger to feel for unusual prostate growth. If a doctor suspects that you have prostate cancer, they might order blood tests and an MRI of your prostate to look for lesions.
If your doctor finds anything unusual on these tests, they may order a biopsy. During a biopsy, a doctor will collect a tissue sample from your prostate. A specialist called a pathologist will then study the sample under a microscope to check for signs of cancer.
Gleason prostate cancer score
Dr. Donald Gleason originally developed the Gleason prostate cancer score in the
A pathologist determines the Gleason score by looking at a sample of your prostate tissue under a microscope. They grade the cells in the biopsy on a scale of 1 to 5. Grade 1 cells are fully healthy, whereas grade 5 cells are highly mutated and don’t resemble healthy cells at all.
The pathologist will calculate the Gleason score by adding up the numbers of the most prevalent and the second most prevalent types of cells in the sample.
For example, if the most common cell grade in your sample is 4 and the second most common is 4, the Gleason score would be 8.
A Gleason score of 6 indicates low grade cancer, 7 indicates intermediate cancer, and 8 to 10 indicates high grade cancer.
Gleason score vs. grade groups
The International Society of Urological Pathology released a revised prostate cancer grading system in 2019. The grade group system seeks to simplify Gleason scores and give a more accurate diagnosis.
One of the major issues with the Gleason score is that some scores can have multiple meanings. For example, a score of 7 can mean:
- 3 + 4: The 3 pattern is the most common in the biopsy, and 4 is the second most common. This pattern is considered “favorable” with intermediate risk.
- 4 + 3: The 4 pattern is the most common in the biopsy, and 3 is the second most common. This pattern is considered “unfavorable” and may mean that there is local or metastatic spread.
So, although the Gleason score is 7 in either case, the outlook differs significantly depending on the components of the score.
Here’s an overview of how the two grading systems compare:
| Cancer grade | Grade group | Gleason score |
|---|---|---|
| low to very low | grade group 1 | |
| intermediate | grade group 2 | 7 (3 + 4) |
| intermediate | grade group 3 | 7 (4 + 3) |
| high to very high | grade group 4 | 8 |
| high to very high | grade group 5 | 9 to 10 |
Not all hospitals have switched to the grade group system. Many hospitals may provide both a grade group and a Gleason score to avoid confusion until grade groups become more widely used.
Stage 1 is the least advanced form of prostate cancer. Cancer at this stage is small and has not spread outside your prostate. This stage is marked by a PSA of less than 10 ng/mL, a grade group score of 1, and a Gleason score of 6.
Stage 1 prostate cancer has a 5-year survival rate of
Treatment
Active surveillance has become the recommended management strategy for prostate cancer with a Gleason score of 6 in most people, except for those who have very high volume disease and those who cannot or will not undergo additional biopsies. Active surveillance involves monitoring the cancer over time to see whether further treatment is needed.
Another treatment option is a radical prostatectomy, which is the surgical removal of the prostate.
Doctors might also recommend radiation therapy, either alone or in combination with prostate removal.
In stage 2, the tumor is still confined to your prostate and has not spread to lymph nodes or other parts of your body. A doctor may or may not be able to feel the tumor during a prostate exam, and the tumor may appear on ultrasound imaging. The survival rate is still
The PSA score for stage 2 is less than 20 ng/mL.
Stage 2 cancer can be further divided into three phases depending on the grade group and Gleason score:
- Grade group: 1
- Gleason score: 6 or less
Stage 2B
- Grade group: 2
- Gleason score: 7 (3 + 4)
Stage 2C
- Grade group: 3 or 4
- Gleason score: 7 (4 + 3) or 8
Treatment
Treatment options at stage 2 include:
- Prostatectomy: In addition to removing your prostate, this procedure may involve removing some surrounding lymph nodes.
- Hormone blockade therapy: Doctors may recommend combining this treatment with radiation therapy, especially in people in grade group 3 and those whose biopsy results show cancerous cells in more than 50% of samples. Radiation therapy may involve external beam radiation and/or brachytherapy (internal radiation).
- Active surveillance: Doctors will generally recommend this approach for stages 2A and 2B only.
At stage 3, cancer cells may or may not have spread to tissues outside your prostate. The survival rate for prostate cancer that has not spread to distant parts of your body is still
Like stage 2, stage 3 prostate cancer can be broken down into three substages.
Stage 3A
In this stage, cancer has not spread beyond your prostate or reached any lymph nodes.
- Grade group: 1 to 4
- Gleason score: 8 or less
- PSA: 20 ng/mL or higher
Stage 3B
At this stage, cancer has spread outside your prostate and possibly to the seminal vesicles or other surrounding tissue, but it has not spread to lymph nodes or other parts of your body.
- Grade group: 1 to 4
- Gleason score: 8 or less
- PSA: any level
Stage 3C
The cancer may or may not be growing in areas outside your prostate, such as your lymph nodes or other nearby organs.
- Grade group: 5
- Gleason score: 9 or 10
- PSA: any level
Treatment
Treatment options at stage 3 include:
- external beam radiation plus hormone blockade therapy
- external beam radiation and brachytherapy plus hormone blockade therapy
- radical prostatectomy, usually including the removal of the pelvic lymph nodes, possibly followed by radiation therapy and/or hormone blockade therapy
Active surveillance is typically not an option at stage 3 because the cancer may progress if it’s not treated.
Stage 4 is the most advanced stage of prostate cancer and is divided into two substages. Stage 4 prostate cancer can have any grade group, PSA value, and Gleason score.
By stage 4, cancer has typically spread to distant parts of your body. Once it has spread to other organs, the 5-year survival rate drops to
Here are the subcategories of stage 4 prostate cancer:
Stage 4A
The tumor has spread to nearby lymph nodes but nowhere else in your body.
Stage 4B
The cancer may have spread to distant lymph nodes and other parts of your body, such as other organs or bones.
Treatment
Treatment options at this stage include:
- hormone blockade therapy
- chemotherapy
- external beam radiation
- radiation targeting bones (if the cancer has spread to bone tissue)
Tips for coping with prostate cancer
If you’ve recently received a prostate cancer diagnosis, you may be finding it difficult to manage. You might develop your own way of coping with the diagnosis, but here are some strategies that you may find helpful:
- Research your treatment options.
- Talk with your loved ones about your diagnosis.
- Add stress-relieving activities to your daily routine.
- Try to eat a balanced diet, get enough sleep, and exercise regularly.
- Go to all your medical appointments and take notes.
- Talk with your doctor about your concerns and questions.
- Consider joining a prostate cancer support group.
Here’s a brief summary of how the stages of prostate cancer compare:
| Stage | Gleason score | Grade group | PSA level | Location of cancer in your body |
|---|---|---|---|---|
| 1 | 6 or less | 1 | less than 10 ng/mL | prostate only |
| 2A | 6 or less | 2 | less than 20 ng/mL | prostate only |
| 2B | 7 (3 + 4) | 2 | less than 20 ng/mL | prostate only |
| 2C | 7 (4 + 3) or 8 | 3 or 4 | less than 20 ng/mL | prostate only |
| 3A | 8 or less | 1 to 4 | 20 ng/mL or more | prostate only |
| 3B | 8 or less | 1 to 4 | any | possibly spread to surrounding tissue |
| 3C | 9 or 10 | 5 | any | possibly spread to surrounding tissue |
| 4A | any | any | any | possibly spread to surrounding tissue and nearby lymph nodes |
| 4B | any | any | any | possibly spread to surrounding tissue, nearby lymph nodes, and other parts of your body |
Prostate cancer is most commonly grouped into four stages based on the TNM system from the American Joint Committee on Cancer.
Cancer stages with higher numbers are more advanced than those with lower numbers. Knowing the stage of cancer helps your doctor decide on the best treatment options for you.
Prostate cancer has a very high survival rate when it’s caught early. Visiting your doctor for regular screening is essential for detecting prostate cancer in the early stages.