Stages of Prostate Cancer

Prostate cancer is staged from I to IV. Stage I is a small tumor inside the prostate with a low PSA and a low Gleason score. Stage IV means the cancer has reached nearby lymph nodes or spread to distant parts of the body, such as bone. Your doctor sets the stage from three findings read together: how far the tumor has grown (the TNM system), your PSA level, and your Grade Group, which comes from the Gleason score.

More than 8 in 10 prostate cancers are found while still confined to the prostate or nearby tissue, and the five-year survival rate for those cases is above 99%.

Many patients ask “what are the 4 stages of prostate cancer?” and how each stage affects their treatment options. Understanding your cancer’s stage is crucial for making informed decisions about your care.

Prostate cancer affects the prostate gland. The prostate gland is a small, walnut-shaped gland that produces seminal fluid. Because the prostate is found only in men, prostate cancer only occurs in men.

Prostate cancer occurs when abnormal cells in the prostate begin to multiply faster than normal cells, forming a tumor. It usually grows slowly and is limited to the prostate, but it does sometimes spread or grow quickly. Most men with prostate cancer do not experience symptoms. For a complete guide on Charlotte prostate cancer treatment, download our eBook.

Most doctors utilize the TNM staging system when staging cancers, including prostate cancer. Doctors utilize evaluative tools like diagnostic tests, imaging scans, and possibly surgery to obtain a sample of the tumor. With their findings, they answer the following questions to define the different aspects of the staging system:

• T (Tumor): Where is the tumor located and how large is it?
• N (Node): Has the cancer spread to and affected lymph nodes? If yes, where did it spread and how many nodes is it impacting?
• M (Metastasis): Has the cancer spread to and affected other parts of the body? If yes, where did it spread and how large is that cancer?
• How likely is it that the cancer will spread?
• What are the PSA levels? (More on PSA below)

Using the TNM staging system, oncologists may utilize clinical or pathological staging. These two types of staging indicate to doctors how likely it is the cancer will spread, what treatments to recommend, and other details about the tumor.

Clinical staging is non-invasive as it is done prior to surgery. It might include imaging tests and physical examinations, a needle prostate biopsy, a prostate-specific antigen (PSA) test, and a Gleason score. If your doctor believes more information is needed to accurately stage your cancer, they will move on to pathological staging.

Clinical staging is indicated with a lowercase “c” before the TNM stage.

When using clinical staging to diagnose prostate cancer, doctors largely rely on the prostate-specific antigen (PSA) test. This test measures the levels of PSA, a protein produced by prostate gland cells, in the blood.

Although normal cells produce PSA, cancerous cells produce more of it. Therefore, higher levels of PSA may indicate the presence of prostate cancer. While each case is different, doctors utilize the following metrics to determine the risk of PSA levels:

• Low Risk: PSA level less than 4 ng/mL blood
  At this level, it is unlikely patients have prostate cancer (but not impossible). Depending on your symptoms and circumstances your doctor may recommend a biopsy to glean more definitive information.
• Borderline Risk: PSA level between 4 and 10 ng/mL blood
  If patients test in this range, there is a small chance—about 25%—they have prostate cancer. Your doctor will likely pursue further, more definitive testing.
• Higher Risk: PSA level greater than 10 ng/mL blood
  There is a 50% chance patients with these higher PSA levels have cancer. Your doctor will pursue further testing to determine the extent of your cancer.

Pathological staging is performed following surgery to assess the tumor and its spread. Because it allows doctors to analyze the tumor’s cells closely, pathological staging is generally more accurate.

It is indicated with a lowercase “p” before the TNM stage.

If a biopsy finds cancer, a pathologist assigns a Gleason score. This system ranges from 1 to 5. Scores of 1 indicate the cancerous cells analyzed look like normal prostate cells. Scores of 5 indicate the cells look very abnormal. The scores 2 through 4 describe cells between these two extremes.

Your doctor will utilize samples from two different areas to determine your Gleason score. These two areas are graded, and their numbers are added to determine your Gleason score. Therefore Gleason scores can be as high as 10.

Note: Survival rates come from SEER, which groups prostate cancer by spread (localized, regional, distant) and not by stage number. Stage IV includes both regional and distant disease, so outlook within stage IV varies widely.

Understanding symptoms by stage can help patients recognize changes and seek appropriate care. Early prostate cancer usually causes no symptoms. Urinary changes such as a weak stream or frequent urination are far more often caused by an enlarged prostate (BPH) than by cancer, and only a PSA test, exam and biopsy can tell the difference.

• Most common: No symptoms (asymptomatic)
• Detection: Usually found during routine PSA screening
• Rare symptoms: Very mild urinary changes that may be attributed to aging

• Early Stage 2: Often no noticeable symptoms
• Advanced Stage 2: May include:
  • Slightly more frequent urination, especially at night
  • Weak urine stream
  • Mild difficulty starting urination

• Urinary symptoms: Frequent urination, urgency, weak stream
• Discomfort: Pelvic pressure or discomfort
• Sexual function: May experience erectile dysfunction
• Other: Blood in urine or semen (less common)

• Bone pain: Particularly in hips, spine, ribs, or pelvis
• Severe urinary problems: Difficulty urinating, blood in urine
• Systemic symptoms: Fatigue, unexplained weight loss
• Neurological symptoms: Weakness or numbness in legs/feet if cancer affects spine
• Breathing difficulties: If cancer spreads to lungs

The American Cancer Society provides further details regarding each of these stages, including specific PSA level and Gleason scores and information on sub-stages. Your cancer care team will utilize your prostate cancer’s stage to determine your cancer treatment plan.

Survival rates describe groups of men, not any one person. They come from the National Cancer Institute’s SEER database, which groups prostate cancer by how far it has spread instead of by stage number.

Stage IV includes both regional disease (IVA) and distant disease (IVB), so the outlook within stage IV varies a great deal. A relative survival rate compares men with prostate cancer to men without it. It does not mean most men live only five years, and treatments have improved since these men were diagnosed.

• Active surveillance: Monitoring cancer with regular PSA tests and biopsies
• Radical prostatectomy: Surgical removal of the prostate
• Radiation therapy: External beam or brachytherapy
• Focal therapy: Targeted treatment of specific areas

• Combination approaches: Surgery plus radiation or hormone therapy
• Radiation therapy with hormone therapy: Often the preferred approach
• Radical prostatectomy: With lymph node removal if indicated

• Hormone therapy: Primary treatment to reduce testosterone
• Chemotherapy: For hormone-resistant cancers
• Radiation therapy: For symptom relief and bone pain
• Immunotherapy: Newer targeted treatments
• Clinical trials: Access to experimental therapies

Depending on the stage of your cancer, it is likely your doctor will incorporate radiation therapy into your treatment plan. Radiation uses extremely accurate, high-energy rays to weaken or kill cancer cells. It is non-invasive and often has few symptoms

For lower stages of prostate cancer, radiation therapy may be your first treatment. It is also often used alongside hormone therapy for prostate cancers that have grown to nearby tissues. Even in higher stages of prostate cancer, radiation therapy can be utilized as an additional treatment if surgery does not remove all of the cancer or if the cancer returns.

Modern radiation techniques include:

• External beam radiation therapy (EBRT): Precise targeting from outside the body
• Intensity-modulated radiation therapy (IMRT): Shapes radiation beams to tumor contours
• Stereotactic body radiation therapy (SBRT): High-dose, few-fraction treatment
• Brachytherapy: Radioactive seed implants directly in the prostate

Navigating a prostate cancer diagnosis and treatment, including understanding your cancer’s stage, can be overwhelming. SERO’s dedicated care team is here to help, from explaining the details of your exact diagnosis to offering state-of-the-art radiation treatments.

Our Charlotte cancer doctors specialize in stage-specific treatment approaches, working closely with urologists and medical oncologists to ensure you receive comprehensive, coordinated care tailored to your specific stage and individual needs.

Prostate cancer is a frightening diagnosis, but most patients experience excellent outcomes, especially when detected early. SERO is here to help you achieve the best possible results with advanced treatment options and compassionate, expert care.