Stage 4 is the most advanced stage of prostate cancer and is divided into two letter groups. Stage 4 prostate cancer can have any grade group, PSA value, and Gleason score. By stage 4, cancer has typically spread to distant parts of your body.
Prostate cancer is the second most commonly diagnosed cancer in males, only behind skin cancer. In 2018 alone, nearly 1.3 million new cases of prostate cancer were reported worldwide. Prostate cancer tends to progress slowly and less aggressively than many other types of cancer. If you detect prostate cancer in the early stages, there’s a very high chance of survival. In the United States, the 5-year survival rate with prostate cancer is close to 98 percent . Prostate cancer can be classified into four different stages, depending on how advanced it is. In the first stage, the tumor is only affecting your prostate and hasn’t spread to other tissues. At stage 4, the tumor has spread to tissue beyond the prostate and possibly to distant parts of your body. In this article, we take a deeper look at the different stages of prostate cancer. We also break down all the terminology you’ll need to understand about these stages. Share on Pinterest adamkaz/Getty Images
How prostate cancer is diagnosed and staged Cancer staging helps you and your doctor understand how advanced your cancer is and how much it has spread at the time of diagnosis. Knowing your cancer stage also helps your doctor determine the best treatment options for you and estimate your chance of survival. The most widely used staging system for cancer is the American Joint Committee on Cancer’s TNM system that classifies cancer from stage 1 to stage 4. TNM stands for: Tumor: the size and extent of the tumor
the size and extent of the tumor Nodes: the number or extent of nearby lymph node involvement
the number or extent of nearby lymph node involvement Metastasis: whether cancer has spread to distant sites in the body The TNM scale is used for many types of cancer. When a doctor uses it to determine your prostate cancer stage, they’ll consider several other factors as well, including: prostate-specific antigen (PSA) levels
Gleason prostate cancer score
grade groups PSA levels PSA is a protein made by both normal and cancerous cells in your prostate. A higher PSA level in your blood is associated with an increased risk of developing prostate cancer. Many doctors will send you for further testing if your PSA levels are higher than 4 ng/mL. According to the American Cancer Society , if you have a PSA level between 4 and 10 ng/mL, there’s a 25 percent chance you have prostate cancer. If your PSA level is above 10 ng/mL, there’s a more than 50 percent chance of having prostate cancer. Doctors commonly use PSA testing to screen for prostate cancer, although there has been some controversy to this approach. The American Urological Association currently recommends PSA screening for the following groups: average-risk individuals between the ages of 55 and 69
people with a family history or other risk factors for prostate cancer Doctors also commonly use a digital rectal exam, where they use a gloved finger to feel for abnormal prostate growth. Additional blood tests and an MRI of the prostate to look for lesions might also be done. If your doctor finds anything unusual on these tests, they may request a biopsy. During a biopsy, your doctor will collect a tissue sample from your prostate. The sample will be studied under a microscope to check for signs of cancer. Gleason prostate cancer score Dr. Donald Gleason originally developed the Gleason prostate cancer score in the 1960s as a way to measure how aggressive your prostate cancer may be. A pathologist determines your Gleason score by looking at a biopsy of your prostate tissue under a microscope. They grade the cells in the biopsy on a scale of 1 to 5. Grade 1 cells are healthy prostate, whereas grade 5 cells are highly mutated and don’t resemble healthy cells at all. The pathologist will calculate your Gleason score by adding together the number of the most prevalent type of cell in the sample and the second most prevalent type of cell. For example, if the most common cell grade in your sample is 4 and the second most common is 4, you would have a score of 8. A Gleason score of 6 is considered low-grade cancer, 7 is intermediate, and 8 to 10 is high-grade cancer. Gleason score vs. grade groups The International Society of Urological Pathology released a revised prostate cancer grading system in 2014. The grade group system seeks to simplify Gleason scores and give a more accurate diagnosis. One of the major problems with the Gleason score is that some scores can be made up in different ways. For example, a score of 7 can mean: 3 + 4. The 3 pattern is the most common in the biopsy and 4 is the second most common. This pattern is considered “favorable” intermediate risk.
The 3 pattern is the most common in the biopsy and 4 is the second most common. This pattern is considered “favorable” intermediate risk. 4 + 3. The 4 pattern is the most common in the biopsy and 3 is the second most common. This pattern is considered “unfavorable” and may mean local or metastatic spread. So, although both situations give a Gleason score of 7, they actually have very different prognoses. Here’s an overview of how the two grading systems compare: Cancer grade Grade group Gleason score low to very low grade group 1 < 6 intermediate grade group 2 7 (3 + 4) intermediate grade group 3 7 (4 +3) high to very high grade group 4 8 high to very high grade group 5 9–10 Not all hospitals have switched to the grade group system. Many hospitals give both grade group and Gleason scores to avoid confusion until grade groups become more widely used.
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Stage 1 prostate cancer Stage 1 is the least advanced form of prostate cancer. Cancer in this stage is small and hasn’t spread past the prostate gland. It’s characterized by a PSA of less than 10 ng/mL, a grade group score of 1, and a Gleason score of 6. Stage 1 prostate cancer has a 5-year survival rate of nearly 100 percent . Treatment Active surveillance has become the recommended management strategy for nearly all patients with a Gleason score of 6, except those with very high-volume disease an those who are unwilling or unable to undergo additional biopsies. Active surveillance means monitoring the cancer over time to see if further treatment is needed. Another treatment option is a radical prostatectomy, which is surgical removal of the prostate gland. Radiation therapy may also be recommended, either by itself or with prostate removal.
Stage 2 prostate cancer In stage 2, the tumor is still confined to your prostate and hasn’t spread to lymph nodes or other parts of your body. A doctor may or may not be able to feel the tumor during a prostate exam, and it may appear on ultrasound imaging. The survival rate is still near 100 percent . The PSA score for stage 2 is less than 20 ng/mL. Stage 2 cancer is further divided into three phases depending on the grade group and Gleason scores: Grade group: 1
1 Gleason score: 6 or less Stage 2B Grade group: 2
2 Gleason score: 7 (3 + 4) Stage 2C Grade group: 3 or 4
3 or 4 Gleason score: 7 (4 + 3) or 8 Treatment Treatment options at stage 2 include: removing your prostate and possibly some surrounding lymph nodes
hormone therapy, which is combined with radiation therapy in select patients (grade group 3 or those who have greater than 50 percent positive biopsy cores)
radiation therapy in the form of external beam and/or brachytherapy for select patients
active surveillance is generally only offered for stages 2A and 2B
Stage 3 prostate cancer At stage 3, cancer cells may or may not have spread outside the prostate to other tissues. The survival rate of prostate cancer that hasn’t spread to distant parts of your body is still close to 100 percent . As in stage 2, stage 3 prostate cancer is broken down into three letter subgroups. Stage 3A In this stage, cancer hasn’t spread outside of your prostate or to any lymph nodes. Grade group: 1 to 4
1 to 4 Gleason score: 8 or less
8 or less PSA: 20 ng/mL or higher Stage 3B Cancer at this stage has grown outside your prostate and may have spread to your seminal vesicles or other surrounding tissue. It hasn’t spread to lymph nodes or to other parts of the body. Grade group: 1 to 4
1 to 4 Gleason score: 8 or less
8 or less PSA: any level Stage 3C The cancer may or may not be growing outside your prostate, such as the lymph nodes or other nearby organs. Grade group: 5
5 Gleason score: 9 or 10
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9 or 10 PSA: any level Treatment Treatment options at stage 3 include: external beam radiation plus hormone therapy
radiation (external beam and brachytherapy) plus hormone therapy
radical prostatectomy, usually with removal of the pelvic lymph nodes; radiation therapy and/or hormone therapy may follow Active surveillance is typically not an option for stage 3 disease due to risk of disease progression without treatment.
Stage 4 prostate cancer Stage 4 is the most advanced stage of prostate cancer and is divided into two letter groups. Stage 4 prostate cancer can have any grade group, PSA value, and Gleason score. By stage 4, cancer has typically spread to distant parts of your body. If it has spread to other organs, the 5-year survival rate drops to about 30 percent . Here are the subcategories of stage 4 prostate cancer. Stage 4A The tumor has spread to nearby lymph nodes but nowhere else in the body. Stage 4B The cancer may have spread to distant lymph nodes, as well as other parts of the body such as other organs or bones. Treatment Treatment options at this stage include: hormone therapy
chemotherapy
external beam radiation
radiation targeting bones (if the cancer has spread to bone tissue)
prostate removal or surgery Tips for coping with prostate cancer If you’ve recently been diagnosed with prostate cancer, you may be finding it difficult to cope. You may develop your own way of dealing with your diagnosis, but here are some general tips that you may find helpful: Research your different treatment options.
Talk with your loved ones about your diagnosis.
continue to eat a well-balanced diet, sleep well, and exercise regularly.
Go to all your doctor appointments and take notes.
Talk with your doctor about your concerns and questions.
Consider joining a local support group.
Prostate cancer stages at a glance Here’s a brief summary of how each stage of prostate cancer compares: Stage Gleason score Group grade PSA score Location of cancer in the body 1 6 or less 1 < 10 ng/mL only prostate 2A 6 or less 2 < 20 ng/mL only prostate 2B 7 (3 + 4) 2 < 20 ng/mL only prostate 2C 7 (4 + 3) or 8 3 or 4 < 20 ng/mL only prostate 3A 8 or less 1–4 > 20 ng/mL only prostate 3B 8 or less 1–4 any possibly spread to surrounding tissue 3C 9 or 10 5 any possibly spread to surrounding tissue 4A any any any possibly spread to surrounding tissue, in nearby lymph nodes 4B any any any possibly spread to surrounding tissue, possibly in nearby lymph nodes, in other parts of the body
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