What Does High-Risk Prostate Cancer Mean?

Prostate cancer isn’t just one disease. That’s because not all prostate cancers behave the same way. Some prostate cancers grow slowly, while others grow quickly and spread to other parts of the body, causing more serious illness. 

One way to describe how a particular case of prostate cancer will behave is to use a “risk category.” High-risk and very high-risk prostate cancers are aggressive types of prostate cancer. Fortunately, they are also the least common types of prostate cancer: Only about 25% of prostate cancers fall into this category. 

But how can you tell if prostate cancer is high risk? And what does this mean for treatment?

If you’ve been diagnosed with high-risk or very high-risk prostate cancer, here’s what you need to know. 

What determines if prostate cancer is ‘high risk’?

High-risk and very high-risk prostate cancers grow more aggressively and are often harder to treat. They are more likely to spread outside the prostate and cause more serious illness.

Several pieces of information can help determine if your cancer is high risk, including:

• Your prostate-specific antigen (PSA) level, a blood test that can detect prostate cancer

• How big your tumor feels during a digital rectal exam 

• How many core samples from your prostate biopsy have cancer cells in them

• Your Gleason grade group — or what the cancer cells look like under the microscope

• The number of lymph nodes that have cancer cells in them and if the cancer has spread from the prostate to other areas (also called metastasis)

Your prostate cancer is considered high risk if only one of the following is true:

• Your PSA level is over 20 

• Your Gleason grade group is 4 or 5 

• Your tumor is big enough to grow past your prostate but has not spread to other parts of your body

Your prostate cancer is considered very high risk if at least one of the following is true:

• Your tumor has grown past your prostate and spread to other parts of your body that are near your prostate

• You have two or three of the features from the high-risk category

• Your cancer cells show a primary Gleason pattern 5

What other tests can be helpful?

Very high-risk and high-risk prostate cancers are more likely to spread to other parts of your body — this is called metastasis. Metastasis can be local — meaning the cancer has spread to body parts near the prostate. Or it can be distant — meaning the cancer has spread to body parts that are far away from the prostate like the bones, liver, or chest. 

If you have one of these prostate cancers, you will need imaging studies to look for metastasis. The most common way to do this is with a study called a bone scan. Your team may use other imaging studies to help determine how your cancer is growing and if it has spread beyond your prostate. 

How is high-risk prostate cancer treated?

Unlike low-risk and intermediate-risk prostate cancer, high-risk prostate cancer is treated with a combination of therapies. Most people will need most if not all of the following:

• Hormone therapy: Hormone therapy is also called androgen deprivation therapy (ADT). During hormone therapy, you take medication that blocks the effects of testosterone. Hormone therapy can help shrink cancer cells or slow their growth. 

• Radiation therapy: Radiation therapy uses beams of energy (radiation) to destroy cancer cells. Radiation therapy can be given in two main ways: external beam radiation therapy (EBRT) and brachytherapy. You may need one or both of these types of radiation.

• Surgery: Some people choose to have their entire prostate removed, which also removes the cancer cells. This is called a radical prostatectomy. During the surgery, people also have pelvic lymph node dissection. This procedure removes lymph nodes that may have cancer cells in them. 

Which treatment for high-risk prostate cancer is best? 

The best treatment for high-risk prostate cancer depends on your specific situation. High-risk cancer is more aggressive and may not respond well to certain types of treatment. That’s why your team will recommend a combination of treatments. Your team will work with you to balance the risks and benefits of each treatment combination. 

Your thoughts about treatment may change over time. That’s normal. Keep talking with your healthcare team so that the plan can change with you. 

Why trust our experts?

Written by:

Jennifer Clements, MD, MSEd, NBHWC

Jennifer Clements, MD, MSEd, NBHWC, is a board-certified physician and health coach who is passionate about achieving optimal health through healthy lifestyles. Clements is a diplomate of the American Board of Obesity Medicine and the American Board of Integrative Medicine.

Edited by:

Patricia Pinto-Garcia, MD, MPH

Patricia Pinto-Garcia, MD, MPH, is a medical editor at GoodRx. She is a licensed, board-certified pediatrician with more than a decade of experience in academic medicine.

Reviewed by:

Brandon R. Mancini, MD, MBA, FACRO

Brandon R. Mancini, MD, MBA, FACRO, serves as medical director at BAMF Health in Grand Rapids, Michigan in the emerging field of theranostics. His primary clinical focus is on the treatment of people with metastatic prostate and neuroendocrine cancers.

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