Advanced Prostate Cancer

Staging

As with any type of cancer, doctors use staging information to plan your treatment and to help predict the likely outcome (prognosis) of the therapy you choose. In addition to the advanced stages, information about each of the other stages is also included to help you better understand how the disease can progress over time. Discussing your stage and your treatment options with your doctors will help you select the best plan for your specific type of cancer.

When cancer cells have spread from the prostate into the lymphatic system, blood, bones or other organs, the disease is considered advanced and may require a much more aggressive treatment plan.

Prostate cancer stages are based on the tumor, node, metastasis (TNM) system developed by the American Joint Committee on Cancer (Table 1). The doctor who evaluates the diagnostic tests will assign a clinical stage based on the evaluation of one or more of the following: a prostate biopsy sample, a physical examination and the results of imaging studies (bone scans, MRI scans and CT scans). These tests allow your doctor to determine the size and location of the tumor(s) (T category), and to see whether cancer has spread to nearby lymph nodes (N category) or other parts of the body (M category).

Table 1. AJCC system for classifying prostate cancer

Classification Definition
Tumor (T)
Tx Tumor cannot be evaluated (due to lack of information)
T0 No evidence of a primary tumor
T1* Tumor was not detected during a digital rectal exam (DRE) and cannot be seen on imaging studies (tumor may be discovered during surgery for a reason other than cancer)*
T2
  T2a
  T2b
  T2c
Tumor can be detected during a DRE and is present in the prostate only
Tumor is in half or less of one side (lobe) of the prostate
Tumor is in more than half of one prostate lobe, but has not yet invaded the other lobe
Tumor is in both prostate lobes
T3
  T3a
  T3b
Tumor extends outside of the prostate
Tumor extends outside the prostate on one side or both sides
Tumor has spread to seminal vesicles (the glands on each side of the bladder)
T4 Tumor has spread to tissues near the prostate other than the seminal vesicles, such as the bladder or wall of the pelvis
Nearby (regional) lymph nodes (N)
Nx Nearby lymph nodes are not evaluated
N0 No cancer cells are found in nearby lymph nodes
N1 Cancer cells are found in nearby lymph nodes
Distant metastasis (M)
M0
M1
  M1a
  M1b
  M1c
Cancer has not spread beyond the prostate
Cancer has spread beyond the prostate
Cancer has spread to distant lymph nodes
Cancer has spread to bone
Cancer has spread to another organ or site, with or without bone disease

*When a tumor is found during surgery not related to prostate cancer, it’s further classified as T1a if tumor cells are found in 5 percent or less of the surgically removed prostate tissue, or as T1b if tumor cells are found in more than 5 percent of the surgically removed prostate tissue. Surgery for a reason other than cancer is almost always for the removal of prostate tissue because of the presence of benign enlargement; this surgery is called a “transurethral resection of the prostate” (TURP). A tumor is classified as T1c if it’s found during a needle biopsy, which is done because of an elevated prostate-specific antigen (PSA) level.

 

If your prostate was removed surgically, a pathologist will examine it and assign a more precise pathologic stage (Table 2), which will help determine your prognosis and help you choose a personalized plan that works best for your cancer.

Table 2. Stage of prostate cancer according to AJCC classification

Group/stage TNM classification Gleason score Prostate-specific antigen (PSA) level
I
T1(a-c), N0, M0
T2a, N0, M0
6 or less, or unknown
6 or less, or unknown
Less than 10, or unknown
Less than 10, or unknown
IIA
T1(a-c), N0, M0
T1(a-c), N0, M0
T2a or T2b, N0, M0
T2b, N0, M0
7
6 or less
7 or less
Unknown
Less than 20
10 or higher, but less than 20
Less than 20
Unknown
IIB
T2c, N0, M0
T1 or T2, N0, M0
T1 or T2, N0, M0
Any score
Any score
8 or higher
Any level
20 or higher
Any level
III T3(a-b), N0, M0 Any score Any level
IV
T4, N0, M0
Any T, N1, M0
Any T, Any N, M1
Any score
Any score
Any score
Any level
Any level
Any level

 

The pathologist will also examine a sample from the prostate biopsy under the microscope and assign a grade to the tumor. This grade, known as the Gleason score, ranges from 2 to 10. To determine the Gleason score, the cancerous tissue patterns are given a grade, from one (non-aggressive) to five (very aggressive). The pathologist will assign a low score when the tumor looks more like normal prostate tissue and higher scores when the cancer looks “less differentiated,” or less like normal tissue. Because one tumor may contain multiple grades, the two most dominant grades in the tumor sample are added together. If the most common grade within the tumor is 3 and the second most common type is 2, then the Gleason score is 5. The higher the Gleason score, the more likely the tumor is to spread:

  • Gleason 6 – Tumor tissue is well differentiated, less aggressive and more likely to grow slowly.
  • Gleason 7 – Tumor tissue is somewhat differentiated, moderately aggressive and likely to grow, but it is less likely to spread quickly.
  • Gleason 8 to 10 – Tumor tissue is poorly differentiated or undifferentiated, very aggressive and likely to grow quickly and very likely to spread.

Along with your stage, your doctor will consider your Gleason score and your initial PSA level (before surgery or radiation) when planning the best treatment for you.

According to the AJCC classification, Stages III and IV prostate cancer are considered to be advanced. In these stages, the tumor extends outside of the prostate into nearby tissues, lymph nodes, organs and/or bones.

Stage III is also known as locally advanced prostate cancer, as it has extended beyond the prostate but is still confined to the “local” area of the prostate. Stage IV cancer may be either regional disease, which means the cancer has spread to nearby lymph nodes but has not spread to other parts of the body, or distant disease, which means the cancer has spread to distant lymph nodes, bone or other organs (see Figure 1).

Most cases of advanced prostate cancer begin as early-stage cancer but spread to other areas, such as the bladder, rectum, bones, lungs or liver. Once cells have migrated to other organs and tissues, the cancer is considered to be "advanced," which is almost always signaled by a rising PSA level after the initial treatment. Some patients may be diagnosed with advanced prostate cancer at the original diagnosis.

While the TNM system is the most commonly used staging system in the U.S., the Whitmore-Jewett system used in the past stages the cancer as A, B, C or D. If your doctor uses this system, ask him or her to translate your stage into a stage based on the AJCC system.

Figure 1

 

Talk to your doctor to learn more about your stage and the results of your biopsy and other diagnostic tests so you can work with your health care team to plan a treatment regimen that’s appropriate for you. Don’t be afraid to ask for copies of test results and ask questions about the staging process so you can fully understand how it will affect your care.

Additional Sources of Information

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