Articles on Prostate Cancer
How is prostate cancer staged?
Prostate cancer is one of the most common types of cancer that develops in men and is the second leading cause of cancer deaths in American men, behind lung cancer and just ahead of colorectal cancer. The prognosis for prostate cancer, as with any cancer, depends on how advanced the cancer has become, according to established stage designations.
The prostate gland is a walnut-sized gland present only in men, found in the pelvis below the bladder. The prostate gland wraps around the urethra (the tube through which urine exits the body) and lies in front of the rectum. The prostate gland secretes part of the liquid portion of the semen, or seminal fluid, which carries sperm made by the testes. The fluid is essential to reproduction.
The term to stage a cancer means to describe the evident extent of the cancer in the body at the time that the cancer is first diagnosed.
- Clinical staging of prostate cancer is based on the pathology results, physical examination, PSA, and if appropriate, radiologic studies.
- The stage of a cancer helps doctors understand the extent of the cancer and plan cancer treatment.
- Knowing the overall results of the different treatments of similarly staged prostate cancers can help the doctor and patient make important decisions about choices of treatment to recommend or to accept.
Prostate cancer is comprised nearly always of adenocarcinoma cells -- cells that arise from glandular tissue. Cancer cells are named according to the organ in which they originate no matter where in the body we find such cells.
- If prostate cancer cells spread in the body to the bones, it is labeled prostate cancer metastatic to the bones, not bone cancer.
- Metastasis is the process of cancer spread through the blood or lymphatic system to other organs/areas throughout the body.
- In the late stages of the disease, prostate cancer more commonly metastasizes to lymph nodes in the pelvis and to the bones.
What are the stages of prostate cancer?
Cancer staging is first described using what is called a TNM system. The "T" refers to a description of the size or extent of the primary, or original, tumor. "N" describes the presence or absence of, and extent of spread of the cancer to lymph nodes that may be nearby or further from the original tumor. "M" describes the presence or absence of metastases -- usually distant areas elsewhere in the body other than regional (nearby) lymph nodes to which the cancer has spread. Cancers with specific TNM characteristics are then grouped into stages, and the stages are then assigned Roman numerals with the numerals used in increasing order as the extent of the cancer being staged increases or the cancer prognosis worsens. Prognosis is finally reflected by considering the patient's PSA score at presentation as well as their Gleason score (the grading system used to determine the aggressiveness of prostate cancer) in assigning a final stage designation.
The American Joint Commission on Cancer (AJCC) system for prostate cancer staging is as follows:
- T designations refer to the characteristics of the prostate cancer primary tumor.
- T1 prostate cancers cannot be seen on imaging tests or felt on examination. They may be found incidentally when surgery is done on the prostate for a problem presumed to be benign, or on needle biopsy for an elevated PSA.
- T1a means that the cancer cells comprise less than 5% of the tissue removed.
- T1b means that cancer cells comprise more than 5% of the tissue removed.
- T1c means that the tissue containing cancer was obtained by needle biopsy for an elevated PSA.
- T2 prostate cancers are those that can felt (palpated) on physical examination of the prostate gland (on digital rectal exam) or that can be visualized with imaging studies such as ultrasound, X-ray, or related studies. The prostate gland is comprised of two halves or lobes. The extent of involvement of those lobes is described here.
- T2a means the cancer involves one half of one lobe of the prostate or less.
- T2b means the cancer involves more than half of one lobe but does not involve the other lobe of the prostate.
- T2c means that the cancer has grown into or involves both lobes of the prostate.
- T3 prostate cancers have grown to the extent that the tumor extends outside of the prostate gland. Adjacent tissues, including the capsule around the prostate gland, the seminal vesicles, as well as the bladder neck, may be involved in T3 tumors.
- T3a means that the cancer has extended beyond the capsule (the outer edge) of the prostate gland but not into the seminal vesicles.
- T3b means that the cancer has invaded into the seminal vesicles.
- T4 prostate cancers have spread outside of the prostate gland and have invaded adjacent tissues or organs. This may be determined by examination, biopsy, or imaging studies. T4 prostate cancer may involve the pelvic floor muscles, the urethral sphincter, the bladder itself, the rectum, or the levator muscles or the pelvic wall. T4 tumors have become fixed to or invaded adjacent structures other than the seminal vesicles.
Traditionally, advanced prostate cancer was defined as disease that had widely metastasized beyond the prostate, the surrounding tissue, and the pelvic lymph nodes and was incurable. However, a more contemporary definition includes patients with lower grade disease with an increased risk of progression and/or death from prostate cancer in addition to those with widely metastatic disease.
The National Cancer Institute and the National Comprehensive Cancer Network (NCCN) guidelines on prostate cancer version 2.2017 indicate the following:
CT scan is used for the initial staging in select patients including
- T3 or T4 disease, and
- T1 or T2 disease and nomogram probability of lymph node involvement > 10% may be candidates for pelvic CT. A nomogram is a predictive tool that takes a set of information (data) and makes a prediction about outcomes.
- Standard MRI techniques can be considered for the initial evaluation of high-risk patients including
- T3 or T4 disease, and
- T1 or T2 disease and nomogram indicating probability of lymph node involvement > 10% may be candidates for pelvic MRI.
Bone scan is recommended in the initial evaluation of patients at high risk for skeletal metastases including
- T1 disease with PSA > 20, T2 disease and PSA > 10, Gleason score > 8 or T3/T4 disease; and
- any stage disease with symptoms of bone metastases (for example, bone pain).
N designations refer to the presence or absence of prostate cancer in nearby lymph nodes, including what are referred to as the hypogastric, obturator, internal and external iliac, and sacral nodes.
- N0 means that there is no prostate cancer evident in the nearby nodes.
- N1 means that there is evidence of prostate cancer in the nearby nodes.
- NX means that the lymph nodes cannot or have not been assessed.
M refers to the presence or absence of prostate cancer cells in distant lymph nodes or other organs. Prostate cancer that has spread through the bloodstream most often first spreads into the bones, then into the lungs and liver.
- M0 means that there is no evidence of spread of prostate cancer into distant tissues or organs.
- M1a means that there is spread of prostate cancer into distant lymph nodes.
- M1b means that there is evidence that prostate cancer has spread into bones.
- M1c means that prostate cancer has spread into other distant organs in addition to or instead of into the bones.
Stratifying prostate cancer by risk
The NCCN guidelines stratify prostate cancer by risk. The risk groups are based on the staging of the prostate cancer, the Gleason score, PSA, and number and extent of biopsy cores positive for cancer. The risk stratification may help decide what treatment option is best for each individual.
- Very low risk: stage T1c, Gleason score ≤ 6, Gleason grade group 1, PSA < 10 ng/mL, < 3 prostate biopsy cores positive for cancer, < 50% cancer in any core, PSA density < 0.15 ng/mL/g
- Low risk: stage T1-T2a, Gleason score ≤ 6, Gleason grade group 1, PSA < 10 ng/mL
- Intermediate risk: stage T2b-T2c, Gleason score 3+4 = 7, Gleason grade group 2 or Gleason score 4+3=7, Gleason grade group 3, or PSA 10-20 ng/mL
- High risk: stage T3a or Gleason score 8, Gleason grade group 4, or Gleason 9-10, Gleason grade group 5, PSA > 20 ng/mL
- Very high risk: stage T3b-T4, primary Gleason pattern 5, Gleason grade group 5 or > 4 cores with Gleason 8-10, Gleason grade group 4-5
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What are prostate cancer survival rates by stage?
Staging evaluation is essential for the planning of treatment for prostate cancer.
- A basic staging evaluation includes the patient examination, blood tests, and the prostate biopsy including ultrasound images of the prostate.
- Further testing and calculations may be performed to best estimate a patient's prognosis and help the doctor and patient decide upon treatment options.
Prognosis refers to the likelihood that the cancer can be cured by treatment, and what the patient's life expectancy is likely to be as a consequence of having had a prostate cancer diagnosis.
If a cancer is cured, your life expectancy is what it would have been had you never been diagnosed with prostate cancer. If the cancer cannot be cured due to it recurring in distant locations as metastases, or recurs either locally (where it started) or in an area no longer able to be treated in a curative manner, then estimates can be made of what is likely to be your survival based again on group statistics for people who have been in the same situation.
Nomograms are charts or computer-based tools that use complex math from analysis of many patients' treatment results.
- They help to estimate the likelihood of a patient surviving free of recurrence after a treatment.
- They also can determine the likelihood of a cancer being found confined to the prostate, or spread beyond the prostate, or into the nearby lymph glands.
- Your doctor will likely input the data from your staging evaluation into a nomogram in order to best counsel you regarding your treatment options.
The prognosis for prostate cancer varies widely, and depends on many factors, including the age and health of the patient, the stage of the tumor when it was diagnosed, the aggressiveness of the tumor, and the cancer's responsiveness to treatment, among other factors.
- The 5-year survival rate for most men with local or regional prostate cancer is 100%.
- Ninety-eight percent are alive at 10 years.
- For men diagnosed with prostate cancer that has spread to other parts of the body, the 5-year survival rate is 30%.
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Coping with prostate cancer
The diagnosis of cancer can cause great anxiety to the individual and his family and friends. At times, one may have troubles coping with the diagnosis, the disease, and its treatment. Searching online for information may prove overwhelming also and may not be the best resource. Ask your physician or local hospital about local resources. Often, there are local prostate cancer support groups which may help you cope with your feelings and provide local resources for more knowledge.
You may consider contacting one or more of the following organizations:
- US Prostate Cancer Foundation,
- American Urological Association Foundation,
- Centers for Disease Control and Prevention (CDC),
- American Cancer Society, and
- Patient Advocates for Advanced (Prostate) Cancer Treatment.
The Internet has provided access to a number of sites focusing on prostate cancer treatment and outcomes. The National Cancer Institute and the National Comprehensive Cancer Network (NCCN) have patient information, as well as the American Urological Association.
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American Cancer Society (ACS). <http://www.cancer.org/cancer/prostatecancer/index>.
American Urological Association. "Clinically Localized Prostate Cancer: AUA/ASTRO/SUO Guideline." 2017. <http://www.auanet.org/guidelines/clinically-localized-prostate-cancer-new-(aua/astro/suo-guideline-2017)>.
Byrd, E.S., et al. AJCC Cancer Staging Manual, 7th Ed. New York, NY: Springer, 2009.
The James Buchanan Brady Urological Institute. Johns Hopkins Medicine.
Lu-Yao, G.L., P.C. Albertson, D.F. Moore, et al. "Fifteen-year outcomes following conservative management among men aged 65 years or older with localized prostate cancer." Eur Urol 68.5 (2015): 805-811.
Mottet, Nicolas, et al. "Updated Guidelines for Metastatic Hormone-Sensitive Prostate Cancer: Abiraterone Acetate Combined With Castration Is Another Standard." European Urology 73 (2018): 316-321.
National Comprehensive Cancer Network
"Prostate Cancer." Memorial Sloan Kettering Cancer Center.
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