Prostate cancer stages

Staging prostate cancer is a sometimes-complex process that involves multiple tests, measurements and other factors. The aim is to determine the size, extent and aggressiveness of the cancer.

This article will cover:

• Types of prostate cancer staging
• Understanding prostate cancer’s progression
• Prostate cancer stages
• Prostate cancer survival rate
• Questions to ask during prostate cancer staging

Types of prostate cancer staging

There are two types of staging for prostate cancer.

Clinical staging: This is based on the results of pre-surgery procedures such as a prostate-specific antigen (PSA) test, a digital rectal exam (DRE), a Gleason score (a grade based on how cancer cells behave on a micro level) and imaging tests. A doctor uses these results to determine the stage of the cancer and decide whether to recommend further diagnostic exams, such as a magnetic resonance imaging (MRI) scan.

Pathological staging: This type of staging is based on information uncovered after prostate surgery. The prostate tissue is examined to get a more detailed, and sometimes more accurate, stage of the disease.

Understanding prostate cancer’s progression

To determine the appropriate treatment, doctors need to know how far the cancer has progressed, or its stage. A pathologist, the doctor trained in analyzing cells taken during a prostate biopsy, will provide two starting points—the cancer’s grade and Gleason score.

Cancer grade: When the pathologist examines prostate cancer cells under a microscope, the most common type of cells get a grade of 3 to 5. The area of cancer cells in the prostate are also graded. The higher the grade, the more abnormal the cells.

Gleason score: The two grades are added together to get a Gleason score. This score tells doctors how likely the cancer is to grow and spread.

After a biopsy confirms prostate cancer, the patient may undergo additional tests to see whether it has spread through the blood or lymph nodes to other parts of the body. These tests are usually imaging studies and may include a bone scan, positron emission tomography (PET) scan or computed tomography (CT) scan.

Stages of prostate cancer

Doctors use the results of all these tests to help determine the stage of the prostate cancer, or how far it has progressed. Widely used staging criteria is based on the TNM system developed by the American Joint Committee on Cancer.

TNM staging system

The three key components of the TNM system are:

• T (tumor), which describes the tumor’s size, location and how deep it has grown into the tissue
• N (node), indicating whether cancer cells have spread to nearby lymph nodes or the channels connecting the lymph nodes
• M (metastasis), which refers to whether the cancer cells have spread to distant organs or tissue

The stage of cancer will help doctor and patient determine the most appropriate options for prostate cancer treatment.

Prostate cancer stages range from 1 through 4:

• Stage 1 prostate cancer means the cancer is still limited to the prostate and has not spread.
• Stage 2 prostate cancer means the cancer cells remain confined to the prostate gland, but may be more at risk of spreading than in stage 1.
• Stage 3 prostate cancer means the cancer is locally advanced.
• Stage 4 prostate cancer means the cancer has spread to lymph nodes or to other parts of the body.

Stage 1 prostate cancer

Stage 1 is assigned to early-stage prostate cancer when the cancer cells are still localized to the prostate, meaning they have not spread outside of the prostate gland. 

• Cancer is on one side of the prostate.
• Cancers usually grow slowly.
• PSA level may not be high and the cancer may not be felt during a DRE.
• There is no lymph node involvement nor metastasis.
• Some cancers that are felt during a DRE may still be classified as stage 1 if the Gleason score is 6 or less and the PSA is lower than 10.

Stage 2 prostate cancer

Stage 2 prostate cancer means the cancer has not spread outside the prostate gland, but it's more at risk of growing than cancers in stage 1. Stage 2 prostate cancer has three substages, listed below.

• Stage 2A:
  • The cancer is on one or both sides of the prostate gland.
  • The PSA blood test level is between 10 and 19.
  • The Gleason score is 6 or less.
• Stage 2B:
  • The cancer is on one or both sides.
  • The PSA is lower than 20.
  • The Gleason score is 7.
• Stage 2C:
  • The cancer is on one or both sides.
  • The PSA is lower than 20.
  • The Gleason score is 7 to 8.

Stage 3 prostate cancer

Stage 3 prostate cancer refers to a locally advanced cancer, which means the cancer cells have spread outside their site of origin. The tumor has progressed and is more likely to grow and spread, with results showing a high Gleason score and elevated PSA levels. This stage also has three substages, listed below.

• Stage 3A:
  • The cancer is on one or both sides of the prostate.
  • The PSA is 20 or higher.
  • The Gleason score may be as high as 8.
• Stage 3B:
  • The cancer has spread outside the prostate gland to nearby tissues but not to the lymph nodes.
  • The PSA may be any level.
  • The Gleason score may be up to 8.
• Stage 3C:
  • This stage is similar to 3B, but the cancer may not be growing beyond the prostate.
  • The Gleason score is 9 or 10.

Stage 4 prostate cancer

Stage 4 prostate cancer is an advanced-stage prostate cancer that has spread (metastasized) to distant sites or to the lymph nodes. It's further divided into two substages, listed below.

• Stage 4A: The cancer has spread to nearby lymph nodes but may or may not have spread to nearby tissues.
• Stage 4B: The cancer has spread to another area of the body, such as the bones or distant lymph nodes.

Learn more about metastatic stage 4 prostate cancer

Prostate cancer survival rate

Identifying the stage of cancer not only helps the care team determine a treatment plan, it also helps predict a potential prognosis. This is achieved by calculating the percentage of people with prostate cancer who survive five years or longer after diagnosis compared to people who don’t have that type of cancer. It’s important to remember that this is only a statistic based on all people with prostate cancer several years in the past, so individual patient experiences may vary.

The National Cancer Institute’s Surveillance, Epidemiology and End Results (SEER) Program  bases the survival rate for prostate cancer on where the cancer started and how far the cancer has spread, as detailed below.

Localized: The cancer hasn’t spread beyond the tissue in which it developed. The five-year relative survival rate for localized prostate cancer is 100 percent.

Regional: The cancer has spread to nearby tissues or lymph nodes. The five-year relative survival rate for regional prostate cancer is 100 percent.

Distant: The cancer has spread to farther reaches of the body. The five-year relative survival rate for distant prostate cancer is about 34 percent.

The overall five-year relative survival rate for prostate cancer is 97.1 percent, according to the SEER program.

Keep in mind that the survival rate for prostate cancer depends on a variety of factors, including the patient’s age, overall health and the extent of the disease, so always talk to the care team about the patient’s individual prognosis.

Questions to ask during prostate cancer staging

To help understand the progression of prostate cancer, discuss these questions with the care team:

• What is my Gleason score?
• Has the cancer spread outside my prostate?
• What’s my prostate cancer stage?
• Are other tests needed to determine my cancer stage?
• What are the treatment options for my stage of prostate cancer?
• Can I avoid treatment right now and go on active surveillance?