Prostate Cancer Staging

Prostate Cancer Stages

Staging is the process doctors use to figure out if prostate cancer has spread outside the prostate. If the cancer has spread, they will try to figure out how far it has spread.
The stage of your prostate cancer describes how much cancer is in the body and helps predict how quickly the cancer will grow and spread.
There are 4 stages of prostate cancer:

  • Stage I
  • Stage II
  • Stage III
  • Stage IV

The lower the number, the less the cancer has spread. Some stages are divided into letters, such as Stage IIA. An earlier letter is a lower stage cancer.

How the Prostate Cancer Stage Is Used

You and your doctor will use your staging information to choose the best treatment(s) for you. You should also consider your age, overall health, and personal preferences when choosing a prostate cancer treatment option.

How Prostate Cancer Stage is Determined

Prostate cancer stages are based on:

  • PSA level
  • Biomarker tests, if you’ve had them
  • Biopsy results
  • Any other tests you’ve had

Accurate Diagnosis

The most accurate staging requires an accurate diagnosis. Biomarker tests and a 3D biopsy with or without a multi-parametric MRI ensures the most accurate staging of your prostate cancer.

Gleason Scores and Grade Groups

Biopsy results are given as a Gleason score or Grade Group. Lower scores and grade groups are less serious than higher scores and grade groups.

Gleason Scores

The lowest Gleason score is 6 and the highest is 10:

  • 3+3=6: The lowest grade prostate cancer that currently exists. Cancers graded as less than Gleason 6 (such as 2+3=5) are likely misdiagnosed
  • 3+4=7: Intermediate-grade cancer
  • 4+3=7 and 8-10: High-grade cancer

A lower-grade cancer grows more slowly than a high-grade cancer and is less likely to spread.

Gleason Grade Groups

Gleason scores are often put into Grade Groups ranging from 1 to 5. Grade Group 1 is most likely to grow and spread slowly and Grade Group 5 is most likely to grow and spread quickly:

  • Grade Group 1 = Gleason 6
  • Grade Group 2 = Gleason 3+4=7
  • Grade Group 3 = Gleason 4+3=7Grade Group 4 = Gleason 8
  • Grade Group 5 = Gleason 9-10

The Staging System for Prostate Cancer

A staging system is a way to describe how far a cancer has spread. The American Joint Committee on Cancer TNM system is the most widely used staging system for prostate cancer. It’s based on:

  • T: Size and extent of the main tumor
  • N: Whether the cancer has spread to nearby lymph node
  • M: Whether the cancer has spread, or metastasized, outside the prostate to other parts of the body
  • PSA level at the time of diagnosis
  • Grade Group (based on the Gleason score).

The T score has 2 parts:

  • Clinical staging, based on the results of digital rectal exam, PSA testing, and Gleason score.
  • Pathologic staging is done if you’ve had surgery to remove your prostate. The pathologic T is usually more accurate than the clinical T, since it’s based on samples taken during surgery rather than transrectal biopsy results, which can miss significant cancers in 30 to 40 percent of cases

Higher T, N, and M numbers mean the cancer is more advanced.

Prostate Cancer Treatment by Stage

 

Stage I Prostate Cancer

Stage I prostate cancer is small and has not grown outside the prostate. It usually grows very slowly and may never cause symptoms or health problems.

Stage Grouping

TNM:

  • cT1, N0, M0, or
  • cT2a, N0, M0, or
  • pT2, N0, M0

Grade Group 1

Low Gleason score: 6

Low PSA level: Less than 10

 

Stage I Prostate Cancer Treatment Options

Watchful waiting or active surveillance is often recommended for:

  • Men with no symptoms who are older or have other serious health problems that may limit how long they live
  • Younger, healthier men with low risk prostate cancer after a 3D mapping biopsy

If you prefer to start treatment, options are:

  • Targeted focal cryotherapy
  • Radiation therapy (external beam or brachytherapy) (may lead to overtreatment)
  • Surgery (may lead to overtreatment)

 

Stage II Prostate Cancer

Stage II prostate cancer has not grown outside the prostate. However, if not treated appropriately, Stage II prostate cancer is more likely than Stage I prostate cancer to spread beyond the prostate.

Stage Grouping

Stage IIA:

  • TNM:
    • cT2a or pT2, N0, M0, or
    • cT2b or cT2c, N0, M0
  • Grade Group: 1
  • Gleason score: 6
  • PSA level: Less than 20

Stage IIB:

  • TNM: T1 or T2, N0, M0
  • Grade Group 2
  • Gleason score: 3+4=7
  • PSA level: Less than 20

Stage IIC:

  • TNM: T1 or T2, N0, M0
  • Grade Group 3
  • Gleason score:
    • 4+3=7 or
    • 8
  • PSA level: Less than 20

Stage II Prostate Cancer Treatment Options

Watchful waiting or active surveillance is often recommended for men with no symptoms who are older or have other serious health problems that may limit how long they live.

For younger, healthier men, treatment options include:

  • Targeted focal cryotherapy (for stage IIB or less in younger men or IIC in men over the age of 70 or younger men in poor health)
  • Surgery, which might be followed by external beam radiation therapy
  • External beam radiation, possibly along with hormone therapy
  • Brachytherapy, possibly along with hormone therapy

 

Stage III Prostate Cancer

Stage III prostate cancer has grown outside the prostate but has not reached the bladder or rectum or spread to lymph nodes or distant organs. It’s more likely to come back after treatment than Stage I or II prostate cancer.

Stage Grouping

Stage IIIA:

  • TNM: T1 or T2, N0, M0
  • Grade Group: 1-4
  • Gleason score: 8 or less
  • PSA level: At least 20

Stage IIIB:

  • TNM: T3 or T4, N0, M0
  • Grade Group: 1-4
  • Gleason score: 9 or 10
  • PSA level: At least 20

Stage IIIC:

  • TNM: Any T, N0, M0
  • Grade Group: 5
  • Gleason score: 6-10
  • PSA level: Any

Stage III Prostate Cancer Treatment Options

Men who are older or have other medical problems may choose hormone therapy (by itself) or active surveillance.

Treatment options for healthier men are:

  • External beam radiation therapy plus hormone therapy
  • External beam radiation therapy plus brachytherapy, possibly along with hormone therapy
  • Surgery, possibly with radiation therapy afterward
  • Full cryotherapy in men in poor health

 

Stage IV Prostate Cancer

Stage IV prostate cancer has spread to nearby areas such as the bladder or rectum, to nearby lymph nodes, or to the bones or other organs.

Stage Grouping

Stage IVA:

  • TNM: Any T, N1, M0
  • Grade Group: Any
  • PSA level: Any

Stage IVB:

  • TNM: Any T, any N, M1
  • Grade Group: Any
  • PSA: Any

Stage IV Prostate Cancer Treatment Options

Treatment for Stage IV prostate cancer focuses on controlling the cancer as long as possible and improving quality of life. Occasionally, Stage IV prostate cancer may be curable with some of the same treatments as Stage III prostate cancer.

Men who are older or have other medical problems and don’t have major symptoms from the prostate cancer may choose active surveillance.

For other men, treatment options include:

  • Hormone therapy, possibly along with chemotherapy
  • External beam radiation, possibly along with brachytherapy plus hormone therapy
  • Surgery, possibly with external beam radiation therapy radiation therapy afterward
  • Surgery to relieve symptoms such as bleeding or urinary obstruction
  • Treatments for cancer that’s spread to the bones, such as:
  • Drugs such as Denosumab (Xgeva) or zoledronic acid (Zometa)
  • External beam radiation therapy
  • Radiopharmaceuticals
  • Immunotherapy
  • Other treatments to relieve symptoms