What Informs Your Treatment Options

Understanding Prostate Cancer Risk Groups

If you have been diagnosed with prostate cancer, the next step is finding out how aggressive (fast-growing) the cancer is and if it has spread beyond the prostate.

Many people are familiar with cancer stages (Stages 1 through 4). Prostate cancer is also grouped by risk level. This is called risk stratification.

Knowing your risk group helps your healthcare team decide:

  • If you need more tests
  • Which treatment options may be best for you
  • How likely the cancer is to grow or spread

How Is Prostate Cancer Risk Determined?

Most men are diagnosed after:

  • A higher-than-normal PSA (prostate-specific antigen) blood test result
  • A prostate biopsy
  • Sometimes an MRI before the biopsy

A biopsy confirms if the cells are cancer. The information from the biopsy, along with other test results, is used to place the cancer into a risk group.

Your healthcare provider looks at three main factors:

Together, these help estimate how likely the cancer is to spread outside the prostate.

Biopsy Results

A pathologist examines the biopsy samples under a microscope to see how abnormal the cancer cells look. This is called the grade of the cancer.

The grade may be reported as:

  • ISUP Grade Group 1 to 5. Grade Group 1 is the least aggressive. Grade Group 5 is the most aggressive.
  • Gleason score. The scores range from 6 to 10. A Gleason score of 6 is the least aggressive. A score of 10 is the most aggressive.

Higher grades mean the cancer is more likely to grow and spread.

PSA Level

Your PSA blood test also helps determine your risk group.

PSA levels are generally divided into three ranges:

  • Less than 10 ng/mL
  • 10 to 20 ng/mL
  • More than 20 ng/mL

Higher PSA levels may suggest a greater chance that the cancer has grown beyond the prostate.

Digital Rectal Exam (DRE)

During a digital rectal exam, your healthcare provider gently feels the prostate through the rectum.

The exam may show that:

  • The cancer cannot be felt.
  • The cancer is small and appears to be only in the prostate.
  • The cancer may have grown outside the prostate.
  • The cancer may have spread into nearby tissues, such as the bladder, pelvis, or rectum.

How Risk Groups Are Created

Healthcare providers combine these to place your cancer into a risk group:

  • Biopsy grade
  • PSA level
  • Digital rectal exam findings

Several systems are used to classify prostate cancer risk. These include the D'Amico, American Urological Association (AUA), and National Comprehensive Cancer Network (NCCN) systems. Although these systems differ slightly, they all help guide treatment decisions.

Very Low- and Low-Risk Prostate Cancer

Low-risk prostate cancer usually includes:

  • Cells that are ISUP Grade Group 1 (Gleason score 6)
  • PSA less than 10 ng/mL
  • Cancer that cannot be felt or is small and confined to the prostate

Some men have only a very small amount of cancer found on their biopsy. They may be classified as having very low-risk prostate cancer.

People with very low- or low-risk prostate cancer usually do not need additional imaging tests. Many are good candidates for active surveillance. This means closely monitoring the cancer with regular checkups instead of treating it right away.

Intermediate-Risk Prostate Cancer

Intermediate-risk prostate cancer is when you have one or more of these:

  • Cells that are ISUP Grade Group 2 or 3
  • PSA between 10 and 20 ng/mL
  • Cancer that is larger but still appears to be only in the prostate on a digital rectal exam

Intermediate-risk prostate cancer may be described as favorable or unfavorable. This depends on factors such as:

  • How many intermediate-risk features it has
  • How many biopsy samples have cancer cells

Some men with intermediate-risk prostate cancer will need imaging tests to check if the cancer has spread.

These tests may include:

  • Bone scan
  • CT scan
  • MRI
  • PET scan

If the cancer has not spread, treatment is often recommended. This may include:

  • Surgery
  • Radiation therapy

For some men - especially those with other serious health conditions or favorable intermediate-risk disease - active surveillance may also be an option.

High-Risk Prostate Cancer

High-risk prostate cancer includes any of the following:

  • Cells that are ISUP Grade Group 4 or 5
  • PSA greater than 20 ng/mL
  • Signs on a digital rectal exam that the cancer has grown outside the prostate

People with high-risk prostate cancer usually need imaging tests to look for signs that the cancer has spread.

Treatment often involves more than one approach, such as:

  • Surgery
  • Radiation therapy
  • Hormone therapy

If the Cancer Has Spread

Sometimes imaging tests show that prostate cancer has spread to any of these:

  • Nearby lymph nodes
  • Lymph nodes in other parts of the body
  • Bones
  • Other organs

This is called regional or metastatic prostate cancer.

Some men may still benefit from treatment directed at the prostate. However, treatment usually focuses on systemic therapy, such as hormone therapy. Hormone therapy for this stage is usually combined with other medications, such as newer hormone-blocking drugs or chemotherapy, rather than used alone. Systemic treatments travel throughout the body to treat cancer cells wherever they may be.

Talking with Your Healthcare Team

Risk stratification helps your healthcare team understand how likely your prostate cancer is to grow or spread. Knowing your risk group helps guide decisions about:

  • If you need more imaging tests
  • Which treatments may be best for you
  • If active surveillance may be an option

Talk to your healthcare team if you are unsure about any test results, or you need to ask more questions.

One of the most important parts of a prostate cancer diagnosis is finding out the stage of the cancer. The stage means how far the cancer has grown or spread.

Knowing the stage helps your doctor:

  • Recommend the best treatment for you
  • Decide if more tests are needed
  • Estimate long-term results
  • Discuss survival rates and follow-up care

Prostate cancer staging is complex. But understanding the basics can help you take an active role in your care.

How Is Prostate Cancer Staged? 

Doctors use information from several tests to determine the stage of prostate cancer. These may include:

  • Prostate-specific antigen (PSA) blood test
  • Prostate biopsy
  • Gleason score and Grade Group
  • Physical exam, including a digital rectal exam (DRE)
  • Imaging tests, such as:
  • MRI
  • CT scan
  • Bone scan
  • PSMA PET/CT scan

What is a Prostate Biopsy? 

A prostate biopsy is a procedure in which small samples of tissue are removed from the prostate with a needle. A pathologist looks at these samples under a microscope to determine:

  • If there are cancer cells
  • How fast-growing (aggressive) the cancer may be
  • The Gleason score and Grade Group

Your PSA level, biopsy results, and physical exam help your doctor estimate the risk that the cancer has or will spread.

For men with very-low-risk or low-risk prostate cancer cells, additional imaging tests are often not needed. This is because the chance of spread is small. Men with higher-risk cancer cells may need imaging tests to look for cancer outside the prostate.

The TNM System 

The most commonly used staging system for prostate cancer is the American Joint Committee on Cancer (AJCC) TNM system.

TNM stands for:

  • T (Tumor). This notes the size of the main tumor.
  • N (Nodes). This notes if the cancer has spread to nearby lymph nodes.
  • M (Metastasis). This notes if the cancer has spread to other parts of the body.

These categories are combined with your PSA level and Grade Group. Together these determine an overall stage, from Stage I to Stage IV.

Understanding the T Category 

The T stage (T for tumor) describes the size and extent of the main tumor.

The clinical T (cT)category is how the tumor is felt or seen on an image. The cT can be based on:

  • Digital rectal exam (DRE)
  • MRI results
  • Biopsy results

Clinical T (cT) findings include:

  • T1. The cancer can’t be felt during an exam. It’s usually found because of an elevated PSA or during a prostate procedure.
  • T2. The cancer can be felt. It is only inside the prostate.
  • T3. The cancer has grown outside the prostate.
  • T4. The cancer has spread into nearby tissues, such as the bladder or rectum.

The pathologic T (pT) category is how the cells look under a microscope. This is noted after surgery to remove the prostate (radical prostatectomy). A pathologist examines the prostate tissue under a microscope. The pathologic T category is often more accurate than the clinical T category.

Understanding the N Category 

The N stage (N for node) describes if cancer has spread to nearby lymph nodes in the pelvis. Your doctor may determine the N category using any of these imaging tests:

  • CT scan
  • MRI
  • PSMA PET/CT scan

If lymph nodes are removed during surgery to remove the prostate, the nodes are examined under a microscope. This will determine the pathologic N category.

Understanding the M Category 

The M category (M for metastasis) describes if prostate cancer has spread to other parts of the body, such as:

  • Lymph nodes outside the pelvis
  • Bones
  • Other organs, such as the lungs or liver

The M category is determined with imaging tests such as:

  • Bone scan
  • CT scan
  • MRI
  • PSMA PET/CT scan

In some cases a biopsy of the area where cancer cells are found (metastatic site) is done, but this is not always needed.

The Stages of Prostate Cancer 

Stage I 

Stage I prostate cancer:

  • Is found only in the prostate
  • Is usually low grade (Grade Group 1)
  • Has a PSA less than 10 ng/mL
  • Has not spread to lymph nodes or other parts of the body

These cancers are often slow growing.

Stage II 

Stage II prostate cancer:

  • Is found only in the prostate
  • May have a higher PSA level
  • May have a higher Grade Group
  • Has not spread to lymph nodes or other organs

Stage II is divided into:

  • Stage IIA
  • Stage IIB
  • Stage IIC

These subgroups reflect differences in PSA level, tumor size, and Grade Group.

Stage III 

Stage III prostate cancer is considered locally advanced.

The cancer may:

  • Have a higher PSA level
  • Have a higher Grade Group
  • Grow outside the prostate
  • Spread into nearby tissues, such as the seminal vesicles

Stage III is divided into:

  • Stage IIIA. This has a higher PSA level.
  • Stage IIIB. This means the cancer has grown outside the prostate.
  • Stage IIIC. This is Grade Group 5 (Gleason score 9 or 10).

Stage IV 

Stage IV prostate cancer means the cancer has spread beyond the prostate. Stage IV includes:

  • Stage IVA. The cancer has spread to nearby pelvic lymph nodes.
  • Stage IVB. The cancer has spread to distant lymph nodes, bones, or other organs.

Bone is the most common place for metastatic prostate cancer to spread.

Examples of Staging Results 

Below are some example staging results based on the methods above. Staging results are complex, so your doctor will explain your stage to you in detail. 

Stage I – cT1N0M0. The tumor can’t be felt during an exam, and can’t be seen on ultrasound imaging; Grade Group 1 (Gleason score 6 or less), PSA less than 10 ng/mL.

Stage IIA – cT1N0M0. Grade Group 1, PSA less than 10-20 ng/mL.

Stage IIIB – T4N0M0. The cancer has grown outside the prostate gland and may have spread to nearby tissues such as the bladder or rectum; Grade Group 1 to 4, any PSA.

Stage IVB – any T, any N, M1. The cancer has spread to other parts of the body such as distant lymph nodes, bones, or other organs such as lungs or liver; any Grade Group, any PSA.

Understanding Survival Rates 

Survival rates are only estimates. They are based on data from large groups of people. They can’t predict what will happen for any one person. There are many factors that affect how each person will fare with their cancer. And it’s important to remember that survival rates continue to improve as treatments advance.

According to data from the U.S. Surveillance, Epidemiology, and End Results (SEER) Program:

  • Men with localized prostate cancer (Stages I to IIIA) have a 5-year relative survival rate of more than 99%.
  • Men with regional disease (Stages IIIB to IVA) also have a 5-year relative survival rate of more than 99%.
  • Men with metastatic prostate cancer (Stage IVB) have a 5-year relative survival rate of about 38%.

Questions to Ask Your Doctor 

Understanding your stage can help you make treatment decisions. You may want to ask:

  • What stage is my prostate cancer?
  • What are my PSA level, Gleason score, and Grade Group?
  • Has the cancer spread outside the prostate?
  • Do I need additional imaging tests?
  • How does my stage affect my treatment options?
  • What are the goals of treatment?

Talking with Your Healthcare Team 

Prostate cancer staging is complex, but knowing the basics can help you feel more in charge of your care. Ask your doctor to explain your stage in detail and what it means for your treatment options and follow-up care.