Initial Treatment of Prostate Cancer, by Stage

The stage of your cancer is one of the most important factors in choosing the best way to treat it. Prostate cancer is staged based on the extent (how much the cancer has spread) of the cancer (using T, N, and M categories) and the PSA level and Gleason score (Grade Group) when it is first diagnosed.

For prostate cancers that haven't spread (stages I to III), doctors also use risk groups (based on how far the prostate tumor has grown, PSA level, and prostate biopsy results) to help determine treatment options. Risk groups range from very low risk to very high risk, with lower risk group cancers having a smaller chance of growing and spreading compared to those in higher risk groups.

Other factors, such as your age, overall health, life expectancy, and personal preferences are also taken into account when looking at treatment options. In fact, many doctors determine a man’s possible treatment options based not just on the stage, but on the risk of cancer coming back (recurrence) after the initial treatment and on the man’s life expectancy.

You might want to ask your doctor what factors he or she is considering when discussing your treatment options. Some doctors might recommend options that are different from those listed here.

Stage I

These prostate cancers are small (T1 or T2) and have not grown outside the prostate. They have low Gleason scores (6 or less) and low PSA levels (less than 10). They usually grow very slowly and may never cause any symptoms or other health problems.

For men without any prostate cancer symptoms who are elderly and/or have other serious health problems that may limit their lifespan, observation or active surveillance is often recommended. For men who wish to start treatment, radiation therapy (external beam or brachytherapy) or radical prostatectomy may be options.

Men who are younger and healthy may consider active surveillance (knowing that they may need to be treated later on), radical prostatectomy, or radiation therapy (external beam or brachytherapy). In some men, radical prostatectomy may be followed by radiation and a short course of hormone treatment.

Stage II

Stage II cancers have not yet grown outside of the prostate, but are larger, have higher Gleason scores, and/or have higher PSA levels than stage I cancers. Stage II cancers that are not treated with surgery or radiation are more likely than stage I cancers to eventually spread beyond the prostate and cause symptoms.

As with stage I cancers, observation is often a good option for men whose cancer is not causing any symptoms and who are elderly and/or have other serious health problems. Radiation therapy (external beam or brachytherapy) with or without a course of hormone therapy may also be an appropriate option.

Treatment options for men who are younger and otherwise healthy might include:

• Radical prostatectomy (often with removal of the pelvic lymph nodes). This may be followed by external beam radiation* if during surgery, your cancer is found to have spread beyond the prostate, or if the PSA level is still detectable a few months after surgery.
• External beam radiation only^*
• Brachytherapy only^*
• Brachytherapy and external beam radiation combined^*
• Active surveillance
• Taking part in a clinical trial of newer treatments

^*All of the radiation options might be combined with several months of hormone therapy if there is a greater chance of cancer recurrence based on PSA level and/or Gleason score.

Stage III

Stage III cancers have grown outside the prostate and may have reached the bladder or rectum (T4). They have not spread to lymph nodes or distant organs. These cancers are more likely to come back after treatment than earlier stage tumors.

Treatment options at this stage may include:

• External beam radiation plus hormone therapy
• Radiation (external beam plus brachytherapy) with a course of hormone therapy
• Radical prostatectomy in selected cases (often with removal of the pelvic lymph nodes). This may be followed by radiation therapy and/or hormone therapy.

Men who are older or who have other medical problems may choose less aggressive treatment such as hormone therapy (by itself), external beam radiation or even observation.

Taking part in a clinical trial of newer treatments is also an option for many men with stage III prostate cancer.

Stage IV

Stage IV cancers have already spread to nearby areas such as nearby lymph nodes or to distant organs such as the bones. Most stage IV cancers can’t be cured, but are treatable. The goals of treatment are to keep the cancer under control for as long as possible and to improve a man’s quality of life.

Initial treatment options may include:

• Hormone therapy
• Hormone therapy with chemotherapy
• Hormone therapy with external beam radiation
• Chemotherapy
• Surgery (TURP) to relieve symptoms such as bleeding or urinary obstruction
• Treatments aimed at bone metastases, such as denosumab (Xgeva), a bisphosphonate like zoledronic acid (Zometa), external radiation aimed at bones, or a radiopharmaceutical such as strontium-89, samarium-153 or radium-223
• Observation (for those who are older or have other serious health issues and do not have major symptoms from the cancer)
• Taking part in a clinical trial of newer treatments

Treatment of stage IV prostate cancer may also include treatments to help prevent or relieve symptoms such as pain.

The options above are for the initial treatment of prostate cancer at different stages. But if these treatments aren’t working (the cancer continues to grow and spread) or if the cancer comes back, other treatments might be used, such as immunotherapy. (See Treating Prostate Cancer That Doesn’t Go Away or Comes Back After Treatment.)