What You Should Know About Prostate Cancer Staging

Prostate cancer is one of the most common cancers in men. In fact, about 1 in 8 people with male anatomy will be diagnosed with prostate cancer at some point during their lifetime.

Fortunately, most prostate cancers can be cured with treatment, such as surgery or radiation therapy. But before treatment and prognosis are determined, the cancer care team must determine the cancer’s stage. The word “stage” refers to how extensive the cancer is within the body, along with how aggressively it is expected to behave. The word “staging” refers to the process used to determine the cancer stage.

In this guide, we’ll discuss prostate cancer staging. We’ll start by reviewing the factors that are used to calculate the stage of prostate cancer. Next, we’ll discuss the tests that are commonly used for prostate cancer staging. Finally, we’ll review how prostate cancer staging might affect treatment.

What is prostate cancer staging used for?

For people with a prostate cancer diagnosis, staging provides useful information about prognosis. It also helps healthcare providers make recommendations for treatment.

Prognosis

Staging can predict how a particular prostate cancer may behave. Early stage, low-risk prostate cancer has an excellent prognosis. These cancers are usually cured with treatment and rarely cause cancer death. Advanced (metastatic) prostate cancers, on the other hand, are not considered curable and are often life-threatening.  

Prostate cancer staging allows healthcare providers to set expectations for how prostate cancer will affect a person’s life.

Treatment

Prostate cancer staging is also important for guiding prostate cancer treatment.

Treatment options depend on the stage. For example, treatment of early stage prostate cancer is very different from that of advanced prostate cancer. Staging allows healthcare providers to recommend the most appropriate treatment for each person.

What information is used for prostate cancer staging?

A combination of the following factors helps determine the stage:

• Blood prostate-specific antigen (PSA) level

• Local tumor extent (also known as T classification)

• Grade group or Gleason Score — a measure of how aggressive the cells appear under the microscope.

• Whether the cancer has metastasized (or spread) to lymph nodes or other parts of the body. Imaging tests, such as CT, MRI, and bone scan, are commonly used to identify metastases.

Are there different types of prostate cancer staging?

There are two categories of staging information for prostate cancer. “Clinical staging” refers to information that comes from physical examination, imaging tests, and blood PSA levels.  “Pathologic staging,” on the other hand, refers to information from a prostate biopsy or surgery.  Both clinical and pathologic staging help determine the overall cancer stage.

The most common staging systems for prostate cancer are the American Joint Commission on Cancer (AJCC) system and the National Comprehensive Cancer Network (NCCN) risk grouping system.

AJCC staging

This system describes the extent of prostate cancer throughout the entire body. It is sometimes referred to as the “TNM” system. This is because it includes information about the tumor’s size (T), lymph node involvement (N), and spread, or metastasis (M). It also includes information about PSA level and Gleason score. Here is a simplified breakdown:

• T classification

  • T1: tumor only identified microscopically (on biopsy)

  • T2: tumor confined to the prostate gland

  • T3: tumor extending through the prostate capsule or invading into the seminal vesicle

  • T4: tumor invading into other nearby organs or tissues

• N classification 

  • N0: no metastasis to lymph nodes in the pelvis

  • N1: metastasis to lymph nodes in the pelvis

• M classification 

  • M0: no distant metastasis (or spread)

  • M1: metastasis to lymph nodes outside of the pelvis or other parts of the body

• The PSA level in the blood

• Grade group, or Gleason Score

The TNM factors are combined to determine the overall cancer stage.

NCCN risk groups

In many cases, prostate cancer is diagnosed before it spreads to lymph nodes or other parts of the body. These are called “localized” tumors. They are classified into “risk groups” based on how likely they are to spread, cause a serious illness, or come back after treatment. The NCCN system is used to classify prostate cancers that have not spread beyond the prostate gland.

The broad NCCN risk categories are:

• Low risk: Tumor confined to the prostate gland, with grade group 1 and PSA below 10 ng/mL. There is also a subcategory of “very low risk.”

• Intermediate risk: Tumor confined to the prostate gland with grade group 2 or 3

and/or PSA between 10-20 ng/mL. This category is also divided into “favorable” and “unfavorable.”

• High risk: Tumor extending through the prostate capsule or into the seminal vesicles and/or grade group 4 or 5 and/or PSA >20 ng/mL. There is also a subcategory of “very high risk.”

How does prostate cancer staging affect treatment options?

As mentioned before, staging helps providers determine the best treatment plan. Much of it depends on whether the cancer remains in the same place where it started or if it has spread to another part of the body.

Localized prostate cancer

In people whose prostate cancer has not spread, staging can help identify the best treatment. Some people are candidates for active surveillance, whereas others may need surgery or radiation therapy.

Staging can also identify people who might benefit from combination treatment. For example, in people getting radiation therapy, treatment may be intensified for people with high-risk prostate cancers. This can mean:

• Combining radiation therapy with antiandrogen therapy

• Combining external-beam radiation with brachytherapy (internal radiation therapy)

Metastatic (stage 4) prostate cancer

Staging studies, particularly imaging tests, can detect metastatic disease. The results of imaging studies may determine the best treatment for an individual with stage 4 disease. Treatment options for patients with metastatic prostate cancer may include:

• Antiandrogen therapy

• Chemotherapy

• Radiation therapy

• Radiopharmaceutical therapy

When, and how often, is prostate cancer staging performed?

Prostate cancer staging is typically done at the time of initial prostate cancer diagnosis. This is called “initial staging.” As mentioned above, staging helps guide the treatment plan.

In many cases, staging may be repeated after treatment in order to see how a person has responded. This is called “restaging.” Restaging may be done multiple times, especially if new treatments are being considered. 

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Written by:

David Marcus, MD

David Marcus, MD, is a board-certified radiation oncologist with expertise in the management of many types of cancer, including prostate cancer, breast cancer, and several others. He earned his medical degree at Emory University in Atlanta, Georgia, where he also completed residency training in radiation oncology.

Edited by:

Mandy Armitage, MD

Mandy Armitage, MD, has combined her interests in clinical medicine with her passion for education and content development for many years. She served as medical director for the health technology companies HealthLoop (now Get Well) and Doximity.

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