Risk Groups for Localized Prostate Cancer

For cancers that have not spread (stage I to III cancers), many doctors now use information about the cancer (such as the T category, initial PSA level, grade group, and prostate biopsy results) to divide them into the following risk groups: 

Very-low-risk group

These prostate cancers are small, not felt on exam, can only be found in a small area of the prostate, and have not grown outside the prostate (cT1c). They have a Grade Group of 1 (Gleason score of 6 or less) and low PSA levels (less than 10) and few other classification criteria. They usually grow very slowly and are unlikely to ever cause any symptoms or other health problems.

Low-risk group

Prostate cancers in this group have not yet grown outside of the prostate, have a Grade Group of 1 (Gleason score of 6 or less) and low PSA levels (less than 10), but are slightly larger (cT1 to cT2a), than very-low-risk cancers.

Intermediate-risk group (favorable or unfavorable)

This group of prostate cancers can be felt on exam or can be seen on an imaging test. The cancer might be found in more than half of one side of the prostate (cT2b) or in both sides of the prostate [cT2c], and/or have a Grade Group of 2 or 3 (Gleason score of 7) and/or a PSA level between 10 and 20 ng/ml. Additional classification split the intermediate-risk group into favorable and unfavorable categories.

High-risk group

Prostate cancers in this group have grown outside the prostate (cT3a) or have a Grade Group of 4 or 5 (Gleason score 8 to 10) or have a PSA level of more than 20. 

Very-high-risk group

These prostate cancers have a very high risk for the tumor growing, coming back, or spreading to the nearby lymph nodes and have one or more of the following traits:

  • The tumor has spread to the seminal vesicles (cT3b) or into other tissues next to the prostate (cT4)
  • The biopsy tissue shows areas with a Gleason 5 pattern (Gleason score 9 or 10 or Grade Group 5)
  • They have 2 or 3 of the features found in the high-risk group (see above)
  • More than 4 biopsy pieces are Grade Group 4 or 5 (Gleason score 8 to 10)

The risk group can help determine if any further tests should be done, as well as help guide initial treatment options. Cancers in lower risk groups have a smaller chance of growing and spreading compared to those in higher risk groups.

If you have prostate cancer that has not spread to nearby lymph nodes or to other parts of the body, you might want to ask your doctor what risk group your cancer falls into to understand your treatment choices. 

Other ways to measure risk of prostate cancer growing and spreading

In addition to the risk groups above, doctors are still learning about the best use of other types of tests and prognostic models to help decide the most effective treatment options for someone. If your doctor suggests using one of these ways to help determine your treatment options, have them explain what it can tell you, as well as how accurate it’s likely to be.

Gene and protein tests for prostate cancer

For men with prostate cancer that is localized (not thought to have spread outside the prostate), a major issue is that it’s often hard to tell how quickly the cancer is likely to grow and spread. This can make it hard to decide if the cancer needs to be treated right away, as well as which types of treatment might be good options. 

Some types of lab tests, known as genomic, molecular, or proteomic tests, can be used along with other information (such as the risk groups above) to help better predict how quickly a prostate cancer might grow or spread, and as a result, help decide what treatment options might be best and when they should be given. These tests look at which genes or proteins are active inside the prostate cancer cells. Examples of such tests include:

  • Oncotype DX Prostate: This test measures the activity of certain genes in prostate cancer cells taken from biopsy tissue and reports it as a score on a scale from 0 to 100 (higher scores indicate a cancer that is more likely to grow and spread quickly, as well as a higher risk of dying from prostate cancer). 
  • Prolaris: This test measures the activity of a different set of genes in prostate cancer cells taken from biopsy tissue and reports it as a score on a scale from 0 to 10 (higher scores indicate a cancer that is more likely to grow and spread quickly, as well as a higher risk of dying from prostate cancer).
  • ProMark: This test measures the activity of a set of proteins in prostate cancer cells taken from biopsy tissue and reports it as a score that helps predict how likely a cancer is to grow and spread quickly.
  • Decipher: For men who choose surgery to treat their cancer, this test measures the activity of certain genes in prostate cancer cells from the surgery tissue. This test can help determine the risk that the cancer will come back in other parts of the body after surgery, and as a result, if these men should consider additional treatment.

These tests continue to be studied to find more areas where they can be useful in prostate cancer risk and treatment decisions.

The American Cancer Society medical and editorial content team

Our team is made up of doctors and oncology certified nurses with deep knowledge of cancer care as well as journalists, editors, and translators with extensive experience in medical writing.

Klein EA. Prostate cancer: Risk stratification and choice of initial treatment. In Savarese DMF, ed. UpToDate. Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com. Last updated May 7, 2021. Accessed August 30, 2021.

National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: Prostate Cancer. Version 1.2022. Accessed at www.nccn.org/professionals/physician_gls/pdf/prostate.pdf on October 4, 2021.

Ross A, D’Amico AV, Freedland S. Molecular prognostic tests for prostate cancer. In Savarese DMF, ed. UpToDate. Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com. Last updated July 2, 2021. Accessed October 4, 2021.

References

Klein EA. Prostate cancer: Risk stratification and choice of initial treatment. In Savarese DMF, ed. UpToDate. Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com. Last updated May 7, 2021. Accessed August 30, 2021.

National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: Prostate Cancer. Version 1.2022. Accessed at www.nccn.org/professionals/physician_gls/pdf/prostate.pdf on October 4, 2021.

Ross A, D’Amico AV, Freedland S. Molecular prognostic tests for prostate cancer. In Savarese DMF, ed. UpToDate. Waltham, Mass.: UpToDate, 2021. https://www.uptodate.com. Last updated July 2, 2021. Accessed October 4, 2021.

Last Revised: January 18, 2022

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