Prostate Cancer Stages and Other Ways to Assess Risk

After a man is diagnosed with prostate cancer, doctors will try to figure out if it has spread, and if so, how far. This process is called staging. The stage of a prostate cancer describes how much cancer is in the body. It helps determine how serious the cancer is and how best to treat it. Doctors also use a cancer's stage when talking about survival statistics.

The stage is based on tests described in Tests to Diagnose and Stage Prostate Cancer, including the blood PSA level and prostate biopsy results.

The AJCC TNM staging system

A staging system is a standard way for the cancer care team to describe how far a cancer has spread. The most widely used staging system for prostate cancer is the AJCC (American Joint Committee on Cancer) TNM system, which was most recently updated in 2018.

The TNM system for prostate cancer is based on 5 key pieces of information:

  • The extent of the main (primary) tumor (T category)*
  • Whether the cancer has spread to nearby lymph nodes (N category)
  • Whether the cancer has spread (metastasized) to other parts of the body (M category)
  • The PSA level at the time of diagnosis
  • The Grade Group (based on the Gleason score), which is a measure of how likely the cancer is to grow and spread quickly. This is determined by the results of the prostate biopsy (or surgery).

*There are 2 types of T categories for prostate cancer:

  • The clinical T category (written as cT) is your doctor’s best estimate of the extent of your disease, based on the results of the physical exam (including a digital rectal exam) and prostate biopsy, and any imaging tests you have had.
  • If you have surgery to remove your prostate, your doctors can also determine the pathologic T category (written as pT). The pathologic T is likely to be more accurate than the clinical T, as it is done after all of your prostate has been examined in the lab.

Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced. Once the T, N, and M categories have been determined, this information is combined (along with the Grade Group and PSA level if they are available) in a process called stage grouping to get the overall stage of the cancer.

The main stages of prostate cancer range from I (1) through IV (4). Some stages are split further (A, B, etc). As a rule, the lower the number, the less the cancer has spread. A higher number, such as stage IV, means cancer has spread more. And within a stage, an earlier letter means a lower stage. Although each person’s cancer experience is unique, cancers with similar stages tend to have a similar outlook and are often treated in much the same way.

Stages of prostate cancer

AJCC Stage

Stage grouping

Stage description

 

 

 

 

 

I

cT1, N0, M0

Grade Group 1 (Gleason score 6 or less)

PSA less than 10

The doctor can’t feel the tumor or see it with an imaging test such as transrectal ultrasound (it was either found during a transurethral resection of the prostate (TURP) or was diagnosed by needle biopsy done for a high PSA) [cT1]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 1, and the PSA level is less than 10.

OR

cT2a, N0, M0

Grade Group 1 (Gleason score 6 or less)  

PSA less than 10

The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in one half or less of only one side (left or right) of the prostate [cT2a]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 1, and the PSA level is less than 10.

OR

pT2, N0, M0

Grade Group 1 (Gleason score 6 or less)

PSA less than 10

The prostate has been removed with surgery, and the tumor was still only in the prostate [pT2]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 1, and the PSA level is less than 10.

 

 

 

 

 

IIA

cT1, N0, M0

Grade Group 1 (Gleason score 6 or less)

PSA at least 10 but less than 20

The doctor can’t feel the tumor or see it with imaging such as transrectal ultrasound (it was either found during a transurethral resection of the prostate (TURP) or was diagnosed by needle biopsy done for a high PSA level) [cT1]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 1. The PSA level is at least 10 but less than 20.

OR

cT2a or pT2, N0, M0

Grade Group 1 (Gleason score 6 or less)

PSA at least 10 but less than 20

The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound and is in one half or less of only one side (left or right) of the prostate [cT2a]. OR the prostate has been removed with surgery, and the tumor was still only in the prostate [pT2].The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 1. The PSA level is at least 10 but less than 20.

OR

cT2b or cT2c, N0, M0

Grade Group 1 (Gleason score 6 or less)

PSA less than 20

The tumor can be felt by digital rectal exam or seen with imaging such as transrectal ultrasound. It is in more than half of one side of the prostate [cT2b] or it is in both sides of the prostate [cT2c]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 1. The PSA level is less than 20.

 

IIB

T1 or T2, N0, M0

Grade Group 2 (Gleason score 3+4=7)

PSA less than 20

The cancer has not yet spread outside the prostate. It might (or might not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound [T1 or T2]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 2. The PSA level is less than 20.

 

IIC

T1 or T2, N0, M0

Grade Group 3 or 4 (Gleason score 4+3=7 or 8)

PSA less than 20

The cancer has not yet spread outside the prostate. It might (or might not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound [T1 or T2]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 3 or 4. The PSA level is less than 20.

 

IIIA

 

T1 or T2, N0, M0

Grade Group 1 to 4 (Gleason score 8 or less)

PSA at least 20

The cancer has not yet spread outside the prostate. It might (or might not) be felt by digital rectal exam or seen with imaging such as transrectal ultrasound [T1 or T2]. The cancer has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 1 to 4. The PSA level is at least 20.

 

IIIB

T3 or T4, N0, M0

Grade Group 1 to 4 (Gleason score 8 or less)

Any PSA

The cancer has grown outside the prostate and might have spread to the seminal vesicles [T3], or it has spread into other tissues next to the prostate, such as the urethral sphincter (muscle that helps control urination), rectum, bladder, and/or the wall of the pelvis [T4]. It has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 1 to 4, and the PSA can be any value.

 

IIIC

Any T, N0, M0

Grade Group 5 (Gleason score 9 or 10)

Any PSA

The cancer might or might not be growing outside the prostate and into nearby tissues [any T]. It has not spread to nearby lymph nodes [N0] or elsewhere in the body [M0]. The Grade Group is 5. The PSA can be any value.

 

IVA

Any T, N1, M0

Any Grade Group

Any PSA

The tumor might or might not be growing into tissues near the prostate [any T]. The cancer has spread to nearby lymph nodes [N1] but has not spread elsewhere in the body [M0]. The Grade Group can be any value, and the PSA can be any value.

 

IVB

Any T, any N, M1

Any Grade Group

Any PSA

The cancer might or might not be growing into tissues near the prostate [any T] and might or might not have spread to nearby lymph nodes [any N]. It has spread to other parts of the body, such as distant lymph nodes, bones, or other organs [M1]. The Grade Group can be any value, and the PSA can be any value.

Prostate cancer staging can be complex. If you have any questions about your stage, please ask someone on your cancer care team to explain it to you in a way you understand.

While the stage of a prostate cancer can help give an idea of how serious the cancer is likely to be, doctors are now looking for other ways to tell how likely a prostate cancer is to grow and spread, which might also help determine a man’s best treatment options.

Prostate cancer risk groups

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

  • Very low 
  • Low
  • Intermediate (favorable or unfavorable)
  • High
  • Very high

The risk group can help determine if any further tests should be done, as well as help guide treatment options.

Other ways to assess risk from prostate cancer

Doctors are still learning about the best use of these types of tests and predictive models. 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.

Genomic and proteomic tests

Another way to get an idea of how quickly a prostate cancer might grow or spread is with lab tests that look at which genes (or proteins) are active inside the prostate cancer cells. Examples of such tests include Oncotype DX Prostate, Prolaris, ProMark, and Decipher. (For more on these tests, see What’s New in Prostate Cancer Research?)

Risk assessment models

Doctors are also studying a number of risk assessment models, which take into account factors such as a man’s overall health and the results of certain lab tests, among other things.

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.

American Joint Committee on Cancer. Prostate. In: AJCC Cancer Staging Manual. 8th ed. New York, NY: Springer; 2017: 715-725.

Klein E. Prostate cancer: Risk stratification and choice of initial treatment. UpToDate. 2019. Accessed at https://www.uptodate.com/contents/prostate-cancer-risk-stratification-and-choice-of-initial-treatment on April 8, 2019.

National Comprehensive Cancer Network (NCCN). Practice Guidelines in Oncology: Prostate Cancer. Version 1.2019. Accessed at www.nccn.org/professionals/physician_gls/pdf/prostate.pdf on March 22, 2019.

Ross A, D’Amico AV, Freedland S. Molecular prognostic tests for prostate cancer. UpToDate. 2019. Accessed at https://www.uptodate.com/contents/molecular-prognostic-tests-for-prostate-cancer on April 8, 2019.

Last Medical Review: August 1, 2019 Last Revised: August 1, 2019

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