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.

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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
  • Nodes: 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:

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.
  • 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 gradeGrade groupGleason score
low to very lowgrade group 1< 6
intermediategrade group 27 (3 + 4)
intermediategrade group 37 (4 +3)
high to very highgrade group 48
high to very highgrade group 59–10

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.

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.

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
  • Gleason score: 6 or less

Stage 2B

  • Grade group: 2
  • Gleason score: 7 (3 + 4)

Stage 2C

  • Grade group: 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

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
  • Gleason score: 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
  • Gleason score: 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
  • Gleason score: 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 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

Here’s a brief summary of how each stage of prostate cancer compares:

StageGleason scoreGroup gradePSA scoreLocation of cancer in the body
16 or less1< 10 ng/mLonly prostate
2A6 or less2< 20 ng/mLonly prostate
2B7 (3 + 4)2< 20 ng/mLonly prostate
2C7 (4 + 3) or 83 or 4< 20 ng/mLonly prostate
3A8 or less1–4> 20 ng/mLonly prostate
3B8 or less1–4anypossibly spread to surrounding tissue
3C9 or 105anypossibly spread to surrounding tissue
4Aanyanyanypossibly spread to surrounding tissue, in nearby lymph nodes
4Banyanyanypossibly spread to surrounding tissue, possibly in nearby lymph nodes, in other parts of the body

Prostate cancer is most commonly grouped into four stages based on the American Joint Committee on Cancer’s TNM system.

Higher stages of cancer are more advanced than lower stages. Knowing which stage your cancer is in helps your doctor determine the best treatment options for you.

Prostate cancer has a very high survival rate when it’s caught early. Visiting your doctor for regular screening is critical for detecting prostate cancer in the early stages.