Prostate Cancer Staging and Risk Assessment

Prostate cancer affected close to 200,000 men in 2020. The prognosis of prostate cancer is usually positive because it typically grows and spreads slowly. Only a small portion of cases turn out to be lethal. The 5-year-relative survival rate of prostate cancer is 97.8%.

It is staged like most other solid tumor cancers, but additional risk assessment tools can be used to help in directing treatment, including whether surgery is needed.

An Elderly Gentleman in His Doctors Office Receiving a Check-Up

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Prostate Cancer Staging

Cancer is staged to determine how much cancer is within the body and if it has spread. This can help a cancer patient determine the best course of treatment and understand their chances of survival.

The TNM system developed by the American Joint Committee on Cancer (AJCC) is the most widely used cancer staging system. T stands for the size and extent of the main tumor, N for the number of nearby lymph nodes that have cancer, and M for metastasis.

A number of tests and procedures are used to stage prostate cancer after a diagnosis is confirmed.

PSA Blood Test

A PSA blood test looks for increased levels of prostate-specific antigens (PSA). When the test is used in men who have already been diagnosed with prostate cancer, it can help determine the stage of their cancer. By combining elevated PSA levels with a physical exam and biopsy results, a doctor can determine how much prostate cancer is in the body and whether or not it has spread to other parts of the body.

Biopsy

A biopsy for prostate cancer is done by removing a part of the prostate to check for abnormal cells and activity. The most common type of biopsy used is the core needle biopsy, a procedure where the doctor inserts a long, thin, and hollow needle through the rectum or the skin between the anus and the scrotum to gather up to 12 samples. A tumor grade will be assigned based on the results, determined by how abnormal the cancer looks under the microscope.

Gleason Score

The Gleason system assigns tumor grades based on how much the cancer looks like normal prostate tissue. The grades run from 1 to 5 (most normal to least normal). Almost all cases of prostate cancer are grade 3 or higher. Since prostate cancers often have areas with different grades, a grade is assigned to the two areas that make up most of the cancer. These two grades are added to yield the Gleason score, which can be between 2 and 10.

Based on the score, prostate cancer is classified into three groups:

  • Well-differentiated or low-grade (a score of 6 or less)
  • Moderately differentiated or intermediate grade (a score of 7)
  • Poorly differentiated or high-grade (a score of 8 to 10)

However, the Gleason score may not always be the best way to describe the grade of cancer because prostate cancer outcomes can be divided into more than just three groups and the scale of the Gleason score can be misleading.

Grade Groups were developed to help bridge the gaps. They range from 1 (most likely to grow and spread slowly) to 5 (most likely to grow and spread quickly). Grade Groups correspond to different Gleason scores:

  • Grade Group 1: Gleason score of 6 or less
  • Grade Group 2: Gleason score of 3+4=7
  • Grade Group 3: Gleason score of 4+3=7
  • Grade Group 4: Gleason score of 8
  • Grade Group 5: Gleason score of 9 and 10
Stages of Prostate Cancer
AJCC Stage Stage Grouping Stage Description
 I
cT1, N0, M0
Grade Group 1
PSA less than 10
OR
cT2a, N0, M0
Grade Group 1 Gleason score 6 or less
PSA less than 10
OR
pT2, N0, M0
Grade Group 1 Gleason score 6 or less
PSA less than 10


The doctor can’t feel the tumor or see it with an imaging test such as transrectal ultrasound (it was either found during a transurethral resection of the prostate or was diagnosed by needle biopsy done for a high PSA). The cancer has not spread to nearby lymph nodes or elsewhere in the body.
OR
The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in one half or less of only one side (left or right) of the prostate. The cancer has not spread to nearby lymph nodes or elsewhere in the body. 
OR
The prostate has been removed with surgery, and the tumor was still only in the prostate. The cancer has not spread to nearby lymph nodes or elsewhere in the body. 
IIA  cT1, N0, M0
Grade Group 1
PSA at least 10 but less than 20
OR
cT2a or pT2, N0, M0
Grade Group 1
PSA at least 10 but less than 20
OR
cT2b or cT2, N0, M0
Grade Group 1
PSA at least 10 but less than 20


The doctor can’t feel the tumor or see it with imaging such as transrectal ultrasound (it was either found during a transurethral resection of the prostate or was diagnosed by needle biopsy done for a high PSA level). The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. 
OR
The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in one half or less of only one side (left or right) of the prostate. Or the prostate has been removed with surgery, and the tumor was still only in the prostate. The cancer has not spread to nearby lymph nodes or elsewhere in the body. 
OR
The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound. It is in more than half of one side of the prostate or it is in both sides of the prostate. The cancer has not spread to nearby lymph nodes or elsewhere in the body. 
IIB T1 or T2, N0, M0
Grade Group 2
PSA less than 20
The cancer has not yet spread outside the prostate. It might (or might not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound. The cancer has not spread to nearby lymph nodes or elsewhere in the body.
IIC T1 or T2, N0, M0
Grade Group 3 or 4
PSA less than 20
The cancer has not yet spread outside the prostate. It might (or might not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound. The cancer has not spread to nearby lymph nodes or elsewhere in the body.
IIIA T1 or T2, N0, M0
Grade Group 1 to 4
PSA at least 20
The cancer has not yet spread outside the prostate. It might (or might not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound. The cancer has not spread to nearby lymph nodes or elsewhere in the body.
IIIB T3 or T4, N0, M0
Grade Group 1 to 4
Any PSA
The cancer has grown outside the prostate and might have spread to the seminal vesicles or other tissues next to the prostate, such as the urethral sphincter, rectum, bladder, and wall of the pelvis. It has not spread to nearby lymph nodes or elsewhere in the body.
IIIC Any T, N0, M0
Grade Group 5
Any PSA
The cancer might or might not be growing outside the prostate and into nearby tissues. It has not spread to nearby lymph nodes or elsewhere in the body.
IVA Any T, N1, M0
Any Grade Group
Any PSA
The tumor might or might not be growing into tissues near the prostate. The cancer has spread to nearby lymph nodes, but has not spread elsewhere in the body. The Grade Group can be any value, and the PSA can be any value.
IVB Any T, any N, M1
Any Grade Group
Any PSA
The cancer might or might not be growing into tissues near the prostate and might or might not have spread to nearby lymph nodes. It has spread to other parts of the body, such as distant lymph nodes, bones, or other organs.

Prostate Cancer Risk Groups

In men newly diagnosed with prostate cancer, doctors will assess each case individually to determine how aggressive the tumor will likely be as well as the appropriate course of treatment. The National Comprehensive Cancer Network (NCCN) developed guidelines to categorize men with prostate cancer into risk groups. They take into account blood test and exam results, genetic testing results, and family history to help determine the appropriate risk group:

  • Very low: Includes people in the T1c stage, Grade Group 1, and who have a PSA of less than 10 ng/mL with PSA density being lower than 0.15 ng/mL, and if the cancer is found in one or two of the biopsies with less than half of all samples showing signs of cancer
  • Low: Includes people in the T1 to T2a stages, Grade Group 1, and a PSA of less than 10 ng/mL
  • Intermediate favorable: Includes people with one intermediate-risk factor who are in Grade Group 1 or 2 and have less than half of their biopsies showing cancerous results
  • Intermediate unfavorable: Includes people in Grade Group 3 with more than half of their biopsies showing cancer and having two or more intermediate risk factors
  • High: Includes people in the T3a stage or Grade Group 4 or 5 or those who have a PSA of more than 20 ng/mL
  • Very high: Includes people in either the T3b or T4 stage or primary Gleason pattern 5, or those who have more than four biopsies showing cancer or two or three high-risk features

Prostate Cancer Risk Assessment

There are different risk assessment tools used to aid with clinical decision-making in addition to the NCCN guidelines.

D’Amico Classification

The D’Amico classification was developed in 1998 and uses factors such as PSA level, Gleason score, and tumor stage to estimate the risk of recurrence of prostate cancer. Because it doesn’t take multiple risk factors into account, it may be less accurate in those who have more than one risk factor.

Nomograms

Five prostate cancer nomograms can be used to assess risk and predict treatment outcomes based on a person’s specific disease characteristics:

  • The pre-radical prostatectomy nomogram is used to predict long-term results and the extent of the cancer following the removal of the prostate gland and surrounding lymph nodes in people who have not yet begun treatment.
  • The post-radical prostatectomy nomogram is used after surgical intervention to predict cancer recurrence at 2, 5, 7, and 10 years after surgery. It is also used to determine the likelihood of survival in the 15 years following surgery.
  • The salvage radiation therapy nomogram is used to predict how effective salvage radiation therapy will be following radical prostatectomy if the cancer recurs. It is also used to determine the probability of cancer control and the levels of undetectable PSA for 6 years following salvage therapy.
  • The risk of dying of prostate cancer in men with a rising PSA after radical prostatectomy nomogram estimates the risk of death if prostate cancer recurs following radical prostatectomy, signaled by rising PSA levels. It predicts the likelihood, in a man initially treated with surgery, that he will die of prostate cancer 5, 10, and 15 years from the time his PSA begins to rise.
  • The risk of high-grade cancer on prostate biopsy nomogram is used to estimate the likelihood of having high-grade prostate cancer in men who have been considered eligible for prostate biopsy by a urologist. This tool is not applicable for men who have already been diagnosed with prostate cancer.

USCF-CAPRA Score

The Cancer of the Prostate Risk Assessment (UCSF-CAPRA) estimates prostate cancer risk based on factors such as age at diagnosis, PSA at diagnosis, Gleason score of the biopsy, clinical stage, and the percentage of biopsy samples that have cancer. Each factor is assigned a score and then added up to calculate a final risk score. Lower scores equal lower risks, and vice versa.

Prostate screening is a personal decision that every man must make for himself, but men age 70 and over should not undergo PSA testing for prostate cancer.

Genomic and Proteomic Tests

Genomic and proteomic tests can be used to get a better idea of the possibility of cancer growth or spread. They look at both genes and proteins that are active inside prostate cancer cells to determine the risk. Some such tests that are used include the Oncotype DX, Prolaris, ProMark, and Decipher.

Prostate Cancer Prediction Tools

In addition to risk assessment tools used to direct cancer treatment, there are also tools used to predict the likelihood that prostate cancer will be found if a biopsy is performed. These tools help prevent overdiagnosis and unnecessary biopsy procedures.

Prostate Cancer Prevention Trial (PCTP) Risk Calculator

The Prostate Cancer Prevention Trial Risk Calculator was developed to help clinicians decide whether a biopsy was needed. It takes into account many clinical factors such as PSA level, exam results, age, race, family history, and biopsy history. The results of the calculator may not apply to all individuals. It should only be used for those who are 55 or older, haven’t been diagnosed with prostate cancer in the past, and have results from a PSA or DRE that are less than 1 year old.

Prostate Biopsy Collaborative Group (PBCG) Risk Calculator

The Prostate Biopsy Collaborative Group Risk Calculator is similar in nature to the PCTP in that it looks at a variety of factors to determine candidacy for a biopsy. It can help to reduce unnecessary biopsies, but this and the PCTP calculators have shown disparities in results across different race groups.

The treatment of prostate cancer is approached with such consideration because the 5-year relative survival rate of all stages combined is high at 98%, and some treatment options may be deemed unnecessary for survivability.

Making Treatment Decisions

Prostate cancer is easily manageable, especially in the early stages. Before undergoing treatment, you may want to discuss options with your doctor so that you're not enduring unnecessary procedures. If you are the type of person who can wait and see, active surveillance or watchful waiting may be a good option before undergoing treatment. It’s also important to consider the type of treatment and how well you can handle it. For those who don’t want to or can’t have surgery, radiation therapy may be a good option.

Treatment side effects should also be taken into consideration, especially if you are in a low-risk group. Some side effects such as incontinence, impotence, and bowel issues may arise. Knowing how much time you’re willing to spend in treatment or recovery will also help you and your physician decide which treatment is best for you.

A Word From Verywell   

Deciding on what course of treatment is best for you may be tough, but it’s a vital part of deciding how you want your prostate cancer treated. If you are not comfortable with the options presented to you, you can always seek a second opinion. Many professionals will favor one form of treatment over the other. For example, a surgical oncologist may push for surgery whereas a radiation oncologist will likely suggest radiation.

Since it can be confusing to choose what is best for you, reaching out and having a discussion with your primary care doctor can help you sort out all the available options. They know you well and can help you decide on what works best for you.  

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Article Sources
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