Prostate Cancer Facts

Prostate Cancer Facts

Posted on: November 29, 2018

Introduction:

ON THIS PAGE: You will find some basic information about this disease and the parts of the body it may affect. This is the first page of Cancer.Net’s Guide to Prostate Cancer. Use the menu to see other pages. Think of that menu as a roadmap for this complete guide.

About the prostate

The prostate is a walnut-sized gland located behind the base of a man’s penis, in front of the rectum, and below the bladder. It surrounds the urethra, the tube-like channel that carries urine and semen through the penis. The prostate’s main function is to make seminal fluid, the liquid in semen that protects, supports, and helps transport sperm.

As men get older, the prostate continues to enlarge over time. This can lead to a condition called benign prostatic hypertrophy (BPH), which is when the urethra becomes blocked. BPH is a common condition associated with growing older, and it can cause symptoms similar to those of prostate cancer. BPH has not been associated with a greater risk of having prostate cancer.

About prostate cancer

Cancer begins when healthy cells in the prostate change and grow out of control, forming a tumor. A tumor can be cancerous or benign. A cancerous tumor is malignant, meaning it can grow and spread to other parts of the body. A benign tumor means the tumor can grow but will not spread.

Prostate cancer is somewhat unusual when compared with other types of cancer. This is because many prostate tumors do not spread quickly to other parts of the body. Some prostate cancers grow very slowly and may not cause symptoms or problems for years or ever. Even when prostate cancer has spread to other parts of the body, it often can be managed for a long time, allowing men even with advanced prostate cancer to live with good health and quality of life for many years. However, if the cancer cannot be well controlled with existing treatments, it can cause symptoms like pain and fatigue and can sometimes lead to death. An important part of managing prostate cancer is monitoring it for growth over time, to determine whether it is growing slowly or quickly. Based on the pattern of growth, your doctor can decide the best available treatment options and when to give them.

About prostate-specific antigen (PSA)

Prostate-specific antigen (PSA) is a protein produced by cells in the prostate gland and released into the bloodstream. PSA levels are measured using a blood test. Although there is no such thing as a “normal PSA” for any man at any given age, a higher-than-normal level of PSA can be found in men with prostate cancer. Other non-cancerous prostate conditions, such as BPH (see above) or prostatitis can also lead to an elevated PSA level. Prostatitis is the inflammation or infection of the prostate. In addition, some activities like ejaculation can temporarily increase PSA levels. This should be avoided before a PSA test to avoid falsely elevated tests. See the * Screening section for more information. (*This will take you to an outside website.)

Histology is how cancer cells look under a microscope. The most common histology found in prostate cancer is called adenocarcinoma. Other, less common histologic types include neuroendocrine prostate cancer and small cell prostate cancer. These rare variants tend to be more aggressive, produce much less PSA, and spread outside the prostate earlier. 

Looking for More of an Introduction?

If you would like more of an introduction, explore these related items. Please note that these links will take you to other sections on Cancer.Net:

ASCO Answers Fact Sheet: Read a 1-page fact sheet that offers an introduction to this type of cancer. This fact sheet is available as a PDF, so it is easy to print out.ASCO Answers Guide: Get this free 44-page booklet that helps you better understand the disease and treatment options. The booklet is available as a PDF, so it is easy to print out.Cancer.Net Patient Education Video: View a short video led by an ASCO expert in this type of cancer that provides basic information and areas of research.Cancer.Net En Español: Read about prostate cancer in Spanish or read a 1-page ASCO Answers Fact Sheet in Spanish. Infórmase sobre cáncer de próstata en español o una hoja informativa de una página, Respuestas sobre el cáncer.

The next section in this guide is Statistics. It helps explain the number of men who are diagnosed with this disease and general survival rates. You may use the menu to choose a different section to read in this guide.

Prostate Cancer: Statistics

Approved by the Cancer.Net Editorial Board, 01/2018

ON THIS PAGE: You will find information about the number of men who are diagnosed with prostate cancer each year. You will also read information on surviving the disease. Remember, survival rates depend on several factors. 

Prostate cancer is the most common cancer among men, except for skin cancer. This year, an estimated 164,690 men in the United States will

be diagnosed with prostate cancer. The average age of diagnosis is 66; the disease rarely occurs before age 40. For unknown reasons, the risk of prostate cancer is 74% higher in black men than in non-Hispanic white men. Most prostate cancers (91%) are found when the disease is confined to the prostate and nearby organs. This is referred to as the local or regional stage.

The 5-year survival rate tells you what percent of men live at least 5 years after the cancer is found. Percent means how many out of 100. The 5-year survival rate for most men with local or regional prostate cancer is nearly 100%. Ninety-eight percent (98%) are alive after 10 years. For men diagnosed with prostate cancer that has spread to other parts of the body, the 5-year survival rate is 30%.

Prostate cancer is the second leading cause of cancer death in men in the United States. It is estimated that 29,430 deaths from this disease will occur this year. Although the number of deaths from prostate cancer continues to decline among all men, the death rate remains twice as high in black men than any other group. A man’s individual survival depends on the type of prostate cancer and the stage of the disease.

It is important to remember that statistics on the survival rates for men with prostate cancer are an estimate. The estimate comes from annual data based on the number of men with this cancer in the United States. Also, experts measure the survival statistics every 5 years. So the estimate may not show the results of better diagnosis or treatment available for less than 5 years. Men should talk with their doctor if they have any questions about this information. 

Statistics adapted from the American Cancer Society’s (ACS) publication, Cancer Facts and Figures 2018, and the ACS website.

The next section in this guide is Medical Illustrations. It offers drawings of body parts often affected by prostate cancer.

Prostate Cancer: Medical Illustrations:

Approved by the Cancer.Net Editorial Board, 03/2018

ON THIS PAGE: You will find a drawing of the main body parts affected by this disease. Use the menu to see other pages.

The illustration shows the male urinary tract. Two kidneys are located on either side of the spine near the bottom of the rib cage. Each kidney connects to a ureter through the renal pelvis and calyx. The ureters run down the body to connect to the bladder, which is located in the pelvic cavity in front of the rectum and directly above the prostate. The prostate is a walnut-sized gland located at the base of the penis. A cross-section of the bladder and prostate shows the 2 ureteric orifices where the ureters connect to the bladder and that the prostate is located directly under the bladder and surrounds the urethra, which allows urine and seminal fluid to exit the body through the penis. Under the prostate, layers of corpus spongiosum tissue and bulbospongiosus muscle surround the urethra. Copyright 2003 American Society of Clinical Oncology.

The next section in this guide is Risk Factors and Prevention. It explains what factors may increase the chance of developing this disease and what men can do to lower their risk. 

Prostate Cancer: Risk Factors and Prevention

Approved by the Cancer.Net Editorial Board, 03/2018

ON THIS PAGE: You will find out more about the factors that increase the chance of developing this type of cancer.

A risk factor is anything that increases a person’s chance of developing cancer. Although risk factors often influence the chance to develop cancer, most do not directly or by themselves cause cancer. Some people with several known risk factors never develop cancer, while others with no known risk factors do. Knowing your risk factors and talking about them with your doctor may help you make more informed lifestyle and health care choices.

The following factors may raise a man’s risk of developing prostate cancer:

Age. The risk of prostate cancer increases with age, especially after age 50. More than 80% of prostate cancers are diagnosed in men who are 65 or older. Older patients who are diagnosed with prostate cancer can face unique challenges, specifically with regard to cancer treatment. For more information, please visit Cancer.Net’s section about aging and cancer.

Race/ethnicity. Black men have a higher risk of prostate cancer than white men. They are also more likely to develop prostate cancer at an earlier age and to have more aggressive tumors that grow quickly. The exact reasons for these differences are not known and may involve genetic, socioeconomic, or other factors. Hispanic men have a lower risk of developing prostate cancer and dying from the disease than non-Hispanic white men.Prostate cancer occurs most often in North America and northern Europe. It also appears that prostate cancer is increasing among Asian men living in urbanized environments, such as Hong Kong, Singapore, and North American and European cities, particularly among those who have a lifestyle with less physical activity and a less healthy diet.

Family history. Prostate cancer that runs in a family, called familial prostate cancer, occurs about 20% of the time. This type of prostate cancer develops because of a combination of shared genes and shared environmental or lifestyle factors.Hereditary prostate cancer, meaning the cancer is inherited from a relative, is rare and accounts for about 5% of all cases. Hereditary prostate cancer occurs when changes in genes, or mutations, are passed down within a family from 1 generation to the next. Hereditary prostate cancer may be suspected if a man’s family history includes any of the following characteristics: 3 or more first-degree relatives with prostate cancerProstate cancer in 3 generations on the same side of the family2 or more close relatives, such as a father, brother, son, grandfather, uncle, or nephew, on the same side of the family diagnosed with prostate cancer before age 55

If a man has a first-degree relative—meaning a father, brother, or son—with prostate cancer, his risk of developing prostate cancer is 2 to 3 times higher than the average risk. This risk increases even further with the number of relatives diagnosed with prostate cancer. 

Hereditary breast and ovarian cancer (HBOC) syndrome. HBOC is associated with DNA-repair mutations to the BRCA1 and/or BRCA2 genes. BRCA stands for “BReast CAncer.” HBOC is most commonly associated with an increased risk of breast and ovarian cancers in women. However, men with HBOC also have an increased risk of developing breast cancer and a more aggressive form of prostate cancer. Mutations in the BRCA1 and BRCA2 genes are thought to cause only a small percentage of familial prostate cancers. Men who have BRCA1 or BRCA2 mutations should consider screening for prostate cancer at an earlier age. Genetic testing may only be appropriate for families with prostate cancer that may also have HBOC. If you are concerned about this based on your own family history, please talk with a genetic counselor or doctor for more information.

Other genetic changes. Other genes that may carry an increased risk of developing prostate cancer include HPC1, HPC2, HPCX, CAPB, ATM, and FANCA. However, none of them has been directly shown to cause prostate cancer or be specific to this disease. Research to identify genes associated with an increased risk of prostate cancer is ongoing, and researchers are constantly learning more about how specific genetic changes can influence the development of prostate cancer. At present, there are no genetic tests available to determine a man’s chance of developing prostate cancer.Agent Orange exposure. The U.S. Department of Veterans Affairs lists prostate cancer as a disease associated with exposure to Agent Orange, a chemical used during the Vietnam War. If you are a veteran who may have been exposed to Agent Orange, please talk to your doctor in the VA system. Learn more about the link with Agent Orange on the Department of Veterans Affairs’ website.Eating habits. No study has proven that diet and nutrition can directly cause or prevent the development of prostate cancer. However, many studies that look at links between certain eating behaviors and cancer suggest there may be a connection. For example, obesity is associated with many cancers, including prostate cancer, and a healthy diet to avoid weight gain is recommended (See “Dietary Changes” below).

Prevention

Different factors cause different types of cancer. Researchers continue to look into what factors cause this type of cancer. Although there is no proven way to completely prevent this disease, you may be able to lower your risk. Talk with your doctor for more information about your personal risk of cancer.

Chemoprevention

A class of drugs called 5-alpha-reductase inhibitors (5-ARIs), which includes dutasteride (Avodart) and finasteride (Proscar), are often used to treat BPH. They may also lower a man’s risk of developing prostate cancer. While some previous clinical trials implied that 5-ARIs were linked to more aggressive prostate cancers, newer studies have suggested that this isn’t true. Interestingly, according to the results of a long-term follow-up study published in 2013, 78% of men either taking finasteride or a placebo were still alive 15 years later. These results suggest that taking finasteride does not decrease the risk of death for men with prostate cancer. This subject remains controversial, and the U.S. Food and Drug Administration (FDA) has not approved these drugs for prostate cancer prevention. However, a 5-ARI is FDA approved for the treatment of lower urinary tract symptoms associated with BPH. Because the decision to take a 5-ARI is different for each patient, any men considering taking this class of medication should discuss the possible benefits and side effects with their doctor.

Dietary changes

There is not enough information right now to make clear recommendations about the exact role eating behaviors play in prostate cancer. Dietary changes may need to be made many years earlier in a man’s life to reduce the risk of developing prostate cancer.

Here is a brief summary of the current research

Regularly eating foods high in fat, especially animal fat, may increase prostate cancer risk. However, no prospective studies, meaning studies that look at men who follow either high-fat or low-fat diets and then measure the total number of men in each group diagnosed with prostate cancer, have yet shown that diets high in animal fat raise the risk of prostate cancer.A diet high in vegetables, fruits, and legumes, such as beans and peas, may decrease the risk of prostate cancer. It is unclear which nutrients are directly responsible. Although lycopene, the nutrient found in tomatoes and other vegetables, has been shown to be associated with a lower risk of prostate cancer, the data so far have not proven a relationship.Currently no specific vitamins, minerals, or other supplements have been conclusively shown in clinical trials to prevent prostate cancer. Men should talk with their doctors before taking any supplements to prevent prostate cancer.Specific changes to eating behaviors may not stop or slow the development of prostate cancer. It is possible such changes would need to be made early in life to have an effect.

The next section in this guide is Screening. It explains how tests may find cancer before signs or symptoms appear. 

Prostate Cancer: Screening

Approved by the Cancer.Net Editorial Board, 03/2018

ON THIS PAGE: You will find out more about screening for this type of cancer. You will also learn the risks and benefits of screening. 

Screening is used to look for cancer before you have any symptoms or signs. When cancer is found earlier, it is often at an earlier stage. This means that there is a better chance of successfully treating the cancer. Scientists have developed, and continue to develop, tests that can be used to screen a person for specific types of cancer. The overall goals of cancer screening are to:

Lower the number of people who die from the disease, or eliminate deaths from cancer altogether.Lower the number of people who develop the disease.

Screening information for prostate cancer

Screening for prostate cancer is done to find evidence of cancer in otherwise healthy men. Two tests are commonly used to screen for prostate cancer:

Digital rectal examination (DRE). A DRE is a test in which the doctor inserts a gloved, lubricated finger into a man’s rectum and feels the surface of the prostate through the bowel wall for any irregularities.PSA blood test. There is controversy about using the PSA test to look for prostate cancer in men with no symptoms of the disease. On the one hand, the PSA test is useful for detecting early-stage prostate cancer, especially in men with many risk factors, which helps some men get the treatment they need before the cancer grows and spreads. On the other hand, PSA screening finds conditions that are not cancer, such as BPH, in addition to very-slow-growing prostate cancers that would never threaten a man’s life. As a result, screening for prostate cancer with PSA may mean that some men have surgery and other treatments that may not be needed, which can cause side effects and seriously affect a man’s quality of life.

ASCO recommends that men with no symptoms of prostate cancer not receive PSA screening if they are expected to live less than 10 years. For men expected to live longer than 10 years, ASCO recommends that they talk with their doctors to find out if the test is appropriate for them.

Other organizations have different recommendations for screening:

The U.S. Preventive Services Task Force (USPSTF) had previously concluded that the potential risks of PSA screening in healthy men outweigh the potential benefits. The latest USPSTF final recommendation statement on prostate cancer screening states that men between 55 and 69 should discuss the pros and cons of PSA screening with their clinician before making a decision about screening. Men who are 70 and older should not have routine PSA screenings for prostate cancer.Both the American Urological Association and the American Cancer Society recommend that men be told the risks and benefits of testing before PSA screening occurs and then make an informed decision in consultation with their doctor.The National Comprehensive Cancer Network considers a patient’s age, PSA value, DRE results, and other factors in their recommendations.

It is not easy to predict which tumors will grow and spread quickly and which will grow slowly. Every man should discuss his situation and personal risk of prostate cancer with his doctor so they can work together to make an informed decision.

The next section in this guide is Symptoms and Signs. It explains what body changes or medical problems this disease can cause. 

Prostate Cancer: Symptoms and Signs

Approved by the Cancer.Net Editorial Board, 03/2018

ON THIS PAGE: You will find out more about body changes and other things that can signal a problem that may need medical care. 

Often, early-stage prostate cancer has no symptoms or signs. It is usually found through a PSA test or DRE, a process called screening. If a PSA test or DRE indicates that prostate cancer may be present, more monitoring and testing is needed to diagnose prostate cancer. When prostate cancer does cause symptoms or signs, it is usually diagnosed in a later stage. These symptoms and signs may include:  

Frequent urinationWeak or interrupted urine flow or the need to strain to empty the bladderThe urge to urinate frequently at nightBlood in the urineBlood in the seminal fluidNew onset of erectile dysfunctionPain or burning during urination, which is much less commonDiscomfort or pain when sitting, caused by an enlarged prostate

Sometimes men with prostate cancer do not have any of these changes. Other noncancerous conditions of the prostate, such as BPH or an enlarged prostate, can cause similar symptoms. Or, the cause of a symptom may be a different medical condition that is not cancer. Urinary symptoms also can be caused by an infection of the bladder or other conditions.

If cancer has spread outside of the prostate gland, a man may experience:

Pain in the back, hips, thighs, shoulders, or other bonesSwelling or fluid buildup in the legs or feetUnexplained weight lossFatigueChange in bowel habits

If you are concerned about any changes you experience, please talk with your doctor. Your doctor will ask how long and how often you have been experiencing the symptom(s), in addition to other questions. This is to help figure out the cause of the problem, called a diagnosis.

If cancer is diagnosed, relieving symptoms remains an important part of cancer care and treatment. This may also be called symptom management, palliative care, or supportive care. Be sure to talk with your health care team about the symptoms you experience, including any new symptoms or a change in symptoms.

The next section in this guide is Diagnosis. It explains what tests may be needed to learn more about the cause of the symptoms. 

Prostate Cancer: Diagnosis

Approved by the Cancer.Net Editorial Board, 03/2018

ON THIS PAGE: You will find a list of common tests, procedures, and scans that doctors use to find the cause of a medical problem. 

Doctors use many tests to find, or diagnose, cancer. They also do tests to learn if cancer has spread to another part of the body from where it started. If this happens, it is called metastasis. For example, imaging tests can show if the cancer has spread. Imaging tests show pictures of the inside of the body. Doctors may also do tests to learn which treatments could work best.

For most types of cancer, a biopsy is the only sure way for the doctor to know whether an area of the body has cancer. In a biopsy, the doctor takes a small sample of tissue for testing in a laboratory. If a biopsy is not possible, the doctor may suggest other tests that will help make a diagnosis, but this situation is rare for prostate cancer. For example, a biopsy may not be done when a patient has another medical problem that makes it difficult to do a biopsy, or when a person has a very high PSA level and a bone scan that indicates cancer.

This list describes options for diagnosing this type of cancer. Not all tests listed below are commonly used for every person. Your doctor may consider these factors when choosing a diagnostic test:

The type of cancer suspectedYour signs and symptomsYour age and medical conditionThe results of earlier medical tests

Preliminary tests

In addition to a physical examination, the following tests may be used to diagnose prostate cancer:

PSA test. As described in the Introduction and Screening sections, PSA is a type of protein released by prostate tissue that is found in higher levels in a man’s blood. Levels can be raised when there is abnormal activity in the prostate, including prostate cancer, BPH, or inflammation of the prostate. Doctors can look at features of the PSA value, such as absolute level, change over time (also known as “PSA velocity”), and level in relation to prostate size, to decide if a biopsy is needed. Free PSA test. There is a version of the PSA test that allows the doctor to measure a specific component, called the “free” PSA. Free PSA is found in the bloodstream and is not bound to proteins. A standard PSA test measures total PSA, which includes both PSA that is and is not bound to proteins. The free PSA test measures the ratio of free PSA to total PSA. Knowing this ratio can sometimes help find out if an elevated PSA level is caused by a malignant condition like prostate cancer. DRE. A doctor uses a DRE to find abnormal parts of the prostate by feeling the area using a finger. It is not very precise and not every doctor has expertise in the technique; therefore, DRE does not usually detect early prostate cancer. See the Screening section for more information.Biomarker tests. A biomarker is a substance that is found in the blood, urine, or body tissues of a person with cancer. It is made by the tumor or by the body in response to the cancer. A biomarker may also be called a tumor marker. Biomarker tests for prostate cancer include the 4K score, which predicts the chances a man will develop high-risk prostate cancer, and the Prostate Health Index (PHI), which predicts the chances a man will develop prostate cancer.

Confirming the diagnosis

If the PSA or DRE test results are abnormal, then the following tests can help confirm a diagnosis of cancer:

PCA3 test. The Prostate CAncer gene 3 (PCA3) assay looks for the PCA3 gene in a man’s urine. Unlike PSA, which can be found in anyone with a prostate, the PCA3 gene is greatly expressed in men with prostate cancer. Using a urine test, a doctor can find out whether this gene is present in the body. This test does not replace PSA. It is used along with a PSA test to help decide if a prostate biopsy is needed.Transrectal ultrasound (TRUS). A doctor inserts a probe into the rectum that takes a picture of the prostate using sound waves that bounce off the prostate. A TRUS is usually done at the same time as a biopsy.Biopsy. A biopsy is the removal of a small amount of tissue for examination under a microscope. Other tests can suggest that cancer is present, but only a biopsy can make a definite diagnosis. To get a tissue sample, a surgeon most often uses TRUS and a biopsy tool to take very small slivers of prostate tissue. Biopsy specimens will be taken from several areas of the prostate. This is done to ensure that a good sample is taken for examination. Most men will have 12 to 14 pieces of tissue removed, and the procedure can take 20 to 30 minutes to complete.A person usually can have this procedure done at the hospital or doctor’s office without needing to stay overnight. The patient is given local anesthesia beforehand to numb the area and usually receives antibiotics before the procedure to prevent infection.A pathologist then analyzes the sample(s) under a microscope. A pathologist is a doctor who specializes in interpreting laboratory tests and evaluating cells, tissues, and organs to diagnose disease.Ask to review the results of the pathology report with your health care team.MRI fusion biopsy. An MRI fusion biopsy combines an MRI scan (see below) with TRUS. Evaluation with a prostate MRI scan has become a routine procedure in clinical practice. The patient first receives an MRI scan to identify suspicious areas of the prostate that require further evaluation. The patient then has an ultrasound of the prostate. Computer software combines these images to produce a 3D image that helps target the precise area where to perform the biopsy. Although it may not eliminate the need for repeat biopsies, an MRI fusion biopsy can better identify areas that are more likely to be cancerous than other methods. An MRI fusion biopsy should only be performed by someone with expertise in the procedure.

Finding out if the cancer has spread

To find out if cancer has spread outside of the prostate, doctors may perform the imaging tests listed below. Doctors are able to estimate the risk of spread, called metastasis, based on PSA levels, tumor grade, and other factors, but an imaging test can confirm this. Men with low-risk early-stage prostate cancer who do not have any symptoms do not need to receive a CT scan or bone scan to figure out the stage of the disease. Learn more about when these tests are recommended to find out if the cancer has spread.

Whole-body bone scan. A bone scan uses a radioactive tracer (Technetium-99) to look at the inside of the bones. The tracer is injected into a patient’s vein. It collects in areas of the bone where metabolic activity has occurred. Healthy bone appears gray to the camera, and areas of injury, such as those caused by cancer, appear dark. It is important to know that structural changes to the bone, such arthritis or bone scars like old fractures, can also be interpreted as abnormal and need to be evaluated by a doctor to make sure they are not cancer.

Computed tomography (CT or CAT) scan. A CT scan creates a 3D picture of the inside of the body using x-rays taken from different angles. A computer combines these images into a detailed, cross-sectional view that shows any abnormalities or tumors. A CT scan can be used to measure the tumor’s size. Sometimes, a special dye called a contrast medium is given before the scan to provide better detail on the image. This dye can be injected into a patient’s vein or given as a liquid to swallow. Positron emission tomography (PET) or PET-CT scan. A PET scan is usually combined with a CT scan (see above), called a PET-CT scan. However, you may hear your doctor refer to this procedure just as a PET scan. A PET scan is a way to create pictures of organs and tissues inside the body. A small amount of a radioactive substance is injected into the patient’s body. This substance is taken up by cells that use the most energy. Because cancer tends to use energy actively, it absorbs more of the radioactive substance. A scanner then detects this substance to produce images of the inside of the body. For many types of cancer, a PET-CT scan uses fluorodeoxyglucose (FDG) as the substance that is imaged; however, FDG is not a useful substance for imaging in prostate cancer and should not be used.Researchers are actively investigating using different substances with PET scans to find prostate cancer. For example, sodium fluoride is absorbed by bones, and its use in a PET scan may improve the chances of finding prostate cancer that has spread to the bone. Other substances being studied include choline acetate, fluciclovine, and prostate specific membrane antigen (PSMA).Magnetic resonance imaging (MRI). An MRI scan uses magnetic fields, not x-rays, to produce detailed images of the body. An MRI can be used to measure the tumor’s size. A special dye called contrast medium is given before the scan to create a clearer picture. This dye can be injected into a patient’s vein or given as a liquid to swallow.

After diagnostic tests are done, your doctor will review all of the results with you. If the diagnosis is cancer, these results also help the doctor describe the cancer. This is called staging.

The next section in this guide is Stages and Grades. It explains the system doctors use to describe the extent of the disease and how the cancer cells look under a microscope. 

Prostate Cancer: Stages and Grades

Approved by the Cancer.Net Editorial Board, 03/2018

ON THIS PAGE: You will learn about how doctors describe a cancer’s growth or spread, as well as what the cancer cells look like under a microscope. This is called the stage and grade.

Staging is a way of describing where the cancer is located, if or where it has spread, and whether it is affecting other parts of the body.

Doctors use diagnostic tests to find out the cancer’s stage, so staging may not be complete until all of the tests are finished. Staging for prostate cancer also involves looking at test results to find out if the cancer has spread from the prostate to other parts of the body. Knowing the stage helps the doctor to decide what kind of treatment is best and can help predict a patient’s prognosis, which is the chance of recovery. There are different stage descriptions for different types of cancer.

There are 2 types of staging for prostate cancer:

Clinical staging. This is based on the results of DRE, PSA testing, and Gleason score (see “Gleason score for grading prostate cancer” below). These test results will help determine whether x-rays, bone scans, CT scans, or MRI are also needed. If scans are needed, they can add more information to help the doctor figure out the clinical stage.Pathologic staging. This is based on information found during surgery, plus the laboratory results, referred to as pathology, of the prostate tissue removed during surgery. The surgery often includes the removal of the entire prostate and some lymph nodes. Examination of the removed lymph nodes can provide more information for pathologic staging.

TNM staging system

One tool that doctors use to describe the stage is the TNM system. Doctors use the results from diagnostic tests and scans to answer these questions:

Tumor (T): How large is the primary tumor? Where is it located?Node (N): Has the tumor spread to the lymph nodes? If so, where and how many?Metastasis (M): Has the cancer metastasized to other parts of the body? If so, where and how much?

The results are combined to determine the stage of cancer for each person. There are 5 stages: stage 0 (zero) and stages I through IV (1 through 4). The stage provides a common way of describing the cancer, so doctors can work together to plan the best treatments.

Here are more details about each part of the TNM system for prostate cancer.

Tumor (T)

Using the TNM system, the “T” plus a letter or number (0 to 4) is used to describe the size and location of the tumor. Some stages are also divided into smaller groups that help describe the tumor in even more detail. Specific tumor stage information is listed below. If the tumor is staged clinically, it is often written as cT. If pathologic staging is used, it is written as pT.

Clinical T

TX: The primary tumor cannot be evaluated.

T0 (T plus zero): There is no evidence of a tumor in the prostate.

T1: The tumor cannot be felt during a DRE and is not seen during imaging tests. It may be found when surgery is done for another reason, usually for BPH or an abnormal growth of noncancerous prostate cells.

T1a: The tumor is in 5% or less of the prostate tissue removed during surgery.T1b: The tumor is in more than 5% of the prostate tissue removed during surgery.T1c: The tumor is found during a needle biopsy, usually because the patient has an elevated PSA level.

T2: The tumor is found only in the prostate, not other parts of the body. It is large enough to be felt during a DRE.

T2a: The tumor involves one-half of 1 side of the prostate.T2b: The tumor involves more than one-half of 1 side of the prostate but not both sides.T2c: The tumor has grown into both sides of the prostate.

T3: The tumor has grown through the prostate on 1 side and into the tissue just outside the prostate.

T3a: The tumor has grown through the prostate either on 1 or both sides of the prostate. This called extraprostatic extension (EPE).T3b: The tumor has grown into the seminal vesicle(s), the tube(s) that carry semen.

T4: The tumor is fixed, or it is growing into nearby structures other than the seminal vesicles, such as the external sphincter, the part of the muscle layer that helps to control urination; the rectum; the bladder; levator muscles; or the pelvic wall.

Pathological T

There is no TX, T0, or T1 classification for pathologic staging of prostate cancer.

T2: The tumor is found only in the prostate.

T3: There is EPE. The tumor has grown through the prostate on 1 or both sides of the prostate.

T3a: There is EPE or the tumor has invaded the neck of the bladder.T3b: The tumor has grown into the seminal vesicle(s).

T4: The tumor is fixed, or it is growing into nearby structures other than the seminal vesicles, such as the external sphincter, the part of the muscle layer that helps to control urination; the rectum; the bladder; levator muscles; or the pelvic wall.

Node (N)

The “N” in the TNM staging system stands for lymph nodes. These tiny, bean-shaped organs help fight infection. Lymph nodes near the prostate in the pelvic region are called regional lymph nodes. Lymph nodes in other parts of the body are called distant lymph nodes.

NX: The regional lymph nodes cannot be evaluated.

N0 (N plus zero): The cancer has not spread to the regional lymph nodes.

N1: The cancer has spread to the regional (pelvic) lymph node(s).

Metastasis (M)

The “M” in the TNM system indicates whether the prostate cancer has spread to other parts of the body, such as the lungs or the bones. This is called distant metastasis.

MX: Distant metastasis cannot be evaluated.

M0 (M plus zero): The disease has not metastasized.

M1: There is distant metastasis.

M1a: The cancer has spread to nonregional, or distant, lymph node(s).M1b: The cancer has spread to the bones.M1c: The cancer has spread to another part of the body, with or without spread to the bone.

Gleason score for grading prostate cancer

Prostate cancer is also given a grade called a Gleason score. This score is based on how much the cancer looks like healthy tissue when viewed under a microscope. Less aggressive tumors generally look more like healthy tissue. Tumors that are more aggressive are likely to grow and spread to other parts of the body. They look less like healthy tissue.

The Gleason scoring system is the most common prostate cancer grading system used. The pathologist looks at how the cancer cells are arranged in the prostate and assigns a score on a scale of 3 to 5 from 2 different locations. Cancer cells that look similar to healthy cells receive a low score. Cancer cells that look less like healthy cells or look more aggressive receive a higher score. To assign the numbers, the pathologist determines the main pattern of cell growth, which is the area where the cancer is most obvious and looks for another area of growth. The doctor then gives each area a score from 3 to 5. The scores are added together to come up with an overall score between 6 and 10.

Gleason scores of 5 or lower are not used. The lowest Gleason score is 6, which is a low-grade cancer. A Gleason score of 7 is a medium-grade cancer, and a score of 8, 9, or 10 is a high-grade cancer. A lower-grade cancer grows more slowly and is less likely to spread than a high-grade cancer.

Doctors look at the Gleason score in addition to stage to help plan treatment. For example, active surveillance (see Treatment Options) may be an option for a patient with a small tumor, low PSA level, and a Gleason score of 6. Patients with a higher Gleason score may need treatment that is more intensive, even if the cancer is not large or has not spread.

Gleason X: The Gleason score cannot be determined.Gleason 6 or lower: The cells are well differentiated, meaning they look similar to healthy cells.Gleason 7: The cells are moderately differentiated, meaning they look somewhat similar to healthy cells.Gleason 8, 9, or 10: The cells are poorly differentiated or undifferentiated, meaning they look very different from healthy cells.

Gleason scores are often grouped into simplified Grade Groups:

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

Cancer stage grouping

Doctors assign the stage of the cancer by combining the T, N, and M classifications. Staging also includes the PSA level (see Screening) and Grade Group.

Stage I: Cancer in this early stage is usually slow growing. The tumor cannot be felt and involves one-half of 1 side of the prostate or even less than that. PSA levels are low. The cancer cells are well differentiated, meaning they look like healthy cells (cT1a–cT1c or cT2a or pT2, N0, M0, PSA level is less than 10, Grade Group 1).

Stage II: The tumor is found only in the prostate. PSA levels are medium or low. Stage II prostate cancer is small but may have an increasing risk of growing and spreading.

Stage IIA: The tumor cannot be felt and involves half of 1 side of the prostate or even less than that. PSA levels are medium, and the cancer cells are well differentiated (cT1a–cT1c or cT2a, N0, M0, PSA level is between 10 and 20, Grade Group 1). This stage also includes larger tumors confined to the prostate as long as the cancer cells are still well differentiated (cT2b–cT2c, N0, M0, PSA level is less than 20, Group 1).Stage IIB: The tumor is found only inside the prostate, and it may be large enough to be felt during DRE. The PSA level is medium. The cancer cells are moderately differentiated (T1–T2, N0, M0, PSA level less than 20, Grade Group 2).Stage IIC: The tumor is found only inside the prostate, and it may be large enough to be felt during DRE. The PSA level is medium. The cancer cells may be moderately or poorly differentiated (T1–T2, N0, M0, PSA level is less than 20, Grade Group 3–4).

Stage III: PSA levels are high, the tumor is growing, or the cancer is high grade. These all indicate a locally advanced cancer that is likely to grow and spread.

Stage IIIA: The cancer has spread beyond the outer layer of the prostate into nearby tissues. It may also have spread to the seminal vesicles. The PSA level is high. (T1–T2, N0, M0, PSA level is 20 or more, Grade Group 1–4).Stage IIIB: The tumor has grown outside of the prostate gland and may have invaded nearby structures, such as the bladder or rectum (T3­–T4, N0, M0, any PSA, Grade Group 1–4).Stage IIIC: The cancer cells across the tumor are poorly differentiated, meaning they look very different from healthy cells (any T, N0, M0, any PSA, Grade Group 5).

Stage IV: The cancer has spread beyond the prostate.

Stage IVA: The cancer has spread to the regional lymph nodes (any T, N1, M0, any PSA, any Grade Group).Stage IVB: The cancer has spread to distant lymph nodes, other parts of the body, or to the bones (any T, N0, M1, any PSA, any Grade Group).

Recurrent: Recurrent prostate cancer is cancer that has come back after treatment. It may come back in the prostate area again or in other parts of the body. If the cancer does return, there will be another round of tests to learn about the extent of the recurrence. These tests and scans are often similar to those done at the time of the original diagnosis.  

Used with permission of the American College of Surgeons, Chicago, Illinois. The original and primary source for this information is the AJCC Cancer Staging Manual, Eighth Edition (2017), published by Springer International Publishing.

Prostate cancer risk groups

In addition to stage, doctors use other prognostic factors to help plan the best treatment and predict how successful treatment will be. Two such risk assessment methods come from the National Comprehensive Cancer Network (NCCN) and the University of California, San Francisco (UCSF).

NCCN

The NCCN developed 4 risk-group categories based on PSA level, prostate size, needle biopsy findings, and the stage of cancer. The lower your risk, the lower the chance that the prostate cancer will grow and spread.

Very low risk. The tumor cannot be felt during a DRE and is not seen during imaging tests but was found during a needle biopsy (T1c). PSA is less than 10 ng/mL. The Gleason score is 6 or less. Cancer was found in fewer than 3 samples taken during a core biopsy. The cancer was found in half or less of any core.Low risk. The tumor is classified as T1a, T1b, T1c, or T2a (see above). PSA is less than 10 ng/mL. The Gleason score is 6 or less.Intermediate risk. The tumor has 2 or more of these characteristics: Classified as T2b or T2c (see above)PSA is between 10 and 20 ng/mLGleason score of 7 High risk. The tumor has 2 or more of these characteristics: Classified as T3a (see above)PSA level is higher than 20 ng/mLGleason score is between 8 and 10 Very high risk. The tumor is classified as T3b or T4 (see above). The histologic grade is 5 for the main pattern of cell growth, or more than 4 biopsy cores have Gleason scores between 8 and 10.

Source: Risk group information is adapted from the NCCN.

UCSF Cancer of the Prostate Risk Assessment (UCSF-CAPRA) score

The UCSF-CAPRA score predicts a man’s chances of having the cancer spread and of dying. This score can be used to help make decisions about the treatment plan. Points are assigned according to a person’s age at diagnosis, PSA level at diagnosis, Gleason score of the biopsy, T classification from the TNM system, and the percentage of biopsy cores involved with cancer. These categories are then used to assign a score between 0 and 10.

CAPRA score 0 to 2 indicates low risk.CAPRA score 3 to 5 indicates intermediate risk.CAPRA score 6 to 10 indicates high risk.   

Information about the cancer’s stage and other prognostic factors will help the doctor recommend a specific treatment plan. The next section in this guide is Treatment Options. 

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