Stages of prostate cancer

Staging describes or classifies a cancer based on how much cancer there is in the body and where it is when first diagnosed. This is often called the extent of the cancer. Information from tests is used to find out the size of the tumour, which parts of the organ have cancer, whether the cancer has spread from where it first started and where the cancer has spread. Your healthcare team uses the stage to plan treatment and estimate the outcome (your prognosis). The following staging information is for adenocarcinoma, which makes up 95% of all prostate cancers. Other types of prostate cancer are staged differently.

The most common staging system for prostate cancer is the AJCC/UICC TNM system. Doctors often also use a simple staging system that describes whether the cancer has spread and if so, where it has spread. Doctors further classify prostate cancers into risk groups based on whether they are likely to come back (recur).

TNM staging system

Simple staging, recurrent prostate cancer and whether the cancer has spread

Risk groups for localized prostate cancer

TNM staging system

The most widely used staging system for prostate cancer is the AJCC (American Joint Committee on Cancer) TNM system. For prostate cancer there are 4 stages. Often the stages 1 to 4 are written as the Roman numerals I, II, III and IV. Generally, the higher the stage number, the more the cancer has spread. The stages can be further divided into A, B or C. An earlier letter means a lower stage. Talk to your doctor if you have questions about staging.

TNM staging is based on the following:

T describes the tumour and whether doctors can feel it or see it on imaging tests. It also describes whether the tumour has grown outside of the prostate to the surrounding tissues. T is usually given as a number from 1 to 4. A higher number means that the tumour takes up more of the prostate or that the tumour has grown outside of the prostate into nearby tissues. Some stages are also divided further into a, b or c. An earlier letter means a lower stage.

The clinical T (cT) is your doctor's best estimate of the extent of the cancer, based on a physical exam, a digital rectal exam (DRE), a prostate biopsy and imaging tests. If you have surgery to remove your prostate, a pathological T (pT) will be given. pT is more accurate than cT.

T Description
T0 There is no evidence of a primary tumour.
T1 The tumour can't be felt during a DRE or seen with an imaging test. It may be found by chance during a biopsy or during surgery for another health issue related to the prostate or bladder.
T1a Cancer is found in 5% or less of the removed tissue.
T1b Cancer is found in more than 5% of the removed tissue.
T1c The tumour is found by needle biopsy in one or both sides of the prostate.
T2 The tumour can be felt by your doctor during a DRE and can be seen on an imaging test. Cancer is only in the prostate.
T2a The tumour is in one half or less of one side of the prostate.
T2b The tumour is in more than half of one side of the prostate.
T2c The tumour is in both sides of the prostate.
T3 The tumour has broken through the outside layer of the prostate gland.
T3a The tumour has grown outside the prostate but not into the seminal vesicles.
T3b The tumour has grown outside the prostate and into the seminal vesicles.
T4

The tumour has grown outside the prostate and into nearby structures such as the bladder, rectum, pelvic muscles and pelvic wall.

Diagram of T1, T2, T3 or T4
Diagram of T1, T2, T3 or T4

N describes whether the cancer has spread to lymph nodes near the prostate. N0 means that the cancer hasn't spread to any nearby lymph nodes. N1 means that it has spread to nearby lymph nodes.

M describes whether the cancer has spread to other parts of the body. M0 means that the cancer has not spread to other parts of the body. M1 means that it has spread to other parts of the body.

PSA level describes the amount of the prostate-specific antigen (PSA) in the blood.

Grade Group (based on the Gleason score) is a measure of how likely the cancer is to grow and spread.

Stage 1

The cancer is only in the prostate, the Grade Group is 1, the PSA level is less than 10 and one of the following is true:

  • The doctor can't feel the tumour or see it with imaging. It was found during a transurethral resection of the prostate (TURP) or by a needle biopsy for a high PSA (cT1, N0, M0).
  • The tumour can be felt during a DRE or seen with imaging and is in one half or less of one side of the prostate (cT2a, N0, M0).
  • The prostate was removed with surgery (pT2, N0, M0).

Stage 2A

The cancer is only in the prostate, the Grade Group is 1 and one of the following is true:

  • The doctor can't feel the tumour or see it with imaging. It was found during a TURP or by a needle biopsy for a high PSA (cT1, N0, M0). The PSA level is between 10 and 20.
  • The tumour can be felt during a DRE or seen with imaging and is in one half or less of one side of the prostate (cT2a, N0, M0). The PSA level is between 10 and 20.
  • The tumour can be felt during a DRE or seen with imaging and is in more than one half of one side of the prostate (cT2b, N0, M0) or it is in both sides of the prostate (cT2c, N0, M0). The PSA level is less than 20.

Stage 2B

The cancer is only in the prostate (T1 or T2, N0, M0). It may or may not be felt during a DRE or seen with imaging. The Grade Group is 2. The PSA level is less than 20.

Stage 2C

The cancer is only in the prostate (T1 or T2, N0, M0). It may or may not be felt during a DRE or seen with imaging. The Grade Group is 3 or 4. The PSA level is less than 20.

Stage 3A

The cancer is only in the prostate (T1 or T2, N0, M0). It may or may not be felt during a DRE or seen with imaging. The Grade Group is 1 to 4. The PSA level is at least 20.

Stage 3B

The cancer has spread outside the prostate but it has not spread to nearby lymph nodes (T3 or T4, N0, M0). The Grade Group is 1 to 4. The PSA level can be any value.

Stage 3C

The cancer may or may not be growing into tissues near the prostate and it has not spread to nearby lymph nodes (any T, N0, M0). The Grade Group is 5. The PSA level can be any value.

Stage 4A

The cancer may or may not be growing into tissues near the prostate and it has spread to nearby lymph nodes (any T, N1, M0). The Grade Group can be any value. The PSA level can be any value.

Stage 4B

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

Recurrent prostate cancer

Recurrent prostate cancer is cancer that has come back after it has been treated. If it comes back in the same place that the cancer first started, it's called local recurrence. If it comes back in tissues or lymph nodes close to where it first started, it's called regional recurrence. It can also recur in another part of the body. This is called distant metastasis or distant recurrence.

Recurrent prostate cancer is also diagnosed when the PSA level starts to rise quickly after initial treatment but there are no other signs of cancer. This is called a biochemical recurrence of prostate cancer.

Whether the cancer has spread

Doctors often divide prostate cancers into groups based on whether the cancer has spread.

Localized means that the cancer is only in the prostate. The cancer hasn't grown into nearby tissues or to distant parts of the body.

Locally advanced means that the cancer has spread outside of the prostate but hasn't spread to lymph nodes or distant parts of the body. It is not metastatic.

Metastatic means that the cancer has spread beyond the tissues surrounding the prostate to lymph nodes or other parts of the body such as the lungs, liver or bones.

Risk groups for localized prostate cancer

Doctors may classify localized prostate cancer into groups based on the risk of the cancer coming back after treatment. They use these risk levels to help them develop treatment plans. Those in higher risk groups are usually offered aggressive treatment. Those in the lower risk groups may be offered active surveillance without immediate treatment.

The risk level is based on the:

Very low risk group has all of the following:

  • T1c stage
  • Grade Group 1
  • PSA level of less than 10 ng/mL
  • cancer in 1 to 2 biopsy cores with no more than half showing cancer
  • PSA density of less than 0.15 ng/mL/g

Low-risk group has all of the following:

  • T1a to T2a stage
  • Grade Group 1
  • PSA level of less than 10 ng/mL

Intermediate-risk group has all of the following:

  • no high-risk group features
  • no very high risk group features
  • one or more of the following intermediate risks:
    • T2b to T2c stage
    • Grade Group 2 or 3
    • PSA level of 10 to 20 ng/mL

Favourable intermediate risk has all of the following:

  • 1 intermediate-risk feature
  • Grade Group 1 or 2
  • cancer in less than half of biopsy cores

Unfavourable intermediate risk has one or more of the following:

  • 2 or more intermediate-risk features
  • Grade Group 3
  • cancer in more than half of biopsy cores

High-risk group has one of the following:

  • T3a stage
  • Grade Group 4 or 5
  • PSA level greater than 20 ng/mL

Very high risk group has one of the following:

  • T3b to T4 stage
  • Grade Group 5
  • more than 4 biopsy cores with Grade Group 4 or 5

Expert review and references

  • Brierley JD, Gospodarowicz MK, Wittekind C (eds.). TNM Classification of Malignant Tumours. 8th ed. Wiley Blackwell; 2017.
  • Djavan B, Bostanci Y, Kazzazi A . Epidemiology, screening, pathology and pathogenesis. Nargund VH, Raghavan D, Sandler HM (eds.). Urological Oncology. Springer; 2015: 39: 677-695.
  • National Comprehensive Cancer Network. NCCN Clinical Practice Guidelines in Oncology: Prostate Cancer (Version 1.2016). http://www.nccn.org/professionals/physician_gls/pdf/prostate.pdf.