Prostate cancer staging

Initial staging is based on the results of PSA blood tests, biopsies, and imaging tests. This is also called clinical staging.

PSA refers to a protein made by the prostate measured by a lab test.

• A higher level of PSA can indicate a more advanced cancer.
• Your health care provider will also look at how fast the PSA levels have been increasing from test to test. A faster increase could show a more aggressive tumor.

A prostate biopsy is done in your provider's office. The results can indicate:

• How much of the prostate is involved.
• The Gleason score. A number from 2 to 10 that shows how closely the cancer cells look like normal cells when viewed under a microscope. Scores 6 or less suggest the cancer is slow growing and not aggressive. Higher numbers indicate a faster growing cancer that is more likely to spread.

Imaging tests such as a CT scan, MRI, or bone scan also may be done.

Using the results from these tests, your provider can tell you your clinical stage. At times, this is enough information to make decisions about your treatment.

Surgical staging (pathological staging) is based on what your provider finds if you have surgery to remove the prostate and perhaps some of the lymph nodes. Lab tests are done on the tissue that's removed.

This staging helps determine what other treatment you may need. It also helps predict what to expect after treatment ends.

The higher the stage, the more advanced the cancer.

Stage I cancer. The cancer is found only in one part of the prostate. Stage I is called localized prostate cancer. It cannot be felt during a digital rectal exam or seen with imaging tests. If the PSA is less than 10 and the Gleason score is 6 or less, Stage I cancer is likely to grow slowly.

Stage II cancer. The cancer is more advanced than stage I. It has not spread beyond the prostate and is still called localized. The cells are less normal than cells in stage I, and may grow more rapidly. There are two types of stage II prostate cancer:

• Stage IIA is found in only one side of the prostate.
• Stage IIB may be found in both sides of the prostate.

Stage III cancer. The cancer has spread outside the prostate into local tissue. It may have spread into the seminal vesicles. These are the glands that make semen. Stage III is called locally advanced prostate cancer.

Stage IV cancer. The cancer has spread to distant parts of the body. It could be in nearby lymph nodes or bones, most often of the pelvis or spine. Other organs such as the bladder, liver, or lungs can be involved.

Staging along with the PSA value and Gleason score helps you and your provider decide on the best treatment, taking into account:

• Your age
• Your overall health
• Your symptoms (if you have any)
• Your feelings about side effects of treatment
• The chance that treatment can cure your cancer or help you in other ways

With stage I, II, or III prostate cancer, the main goal is to cure the cancer by treating it and keeping it from coming back. With stage IV, the goal is to improve symptoms and prolong life. In most cases, stage IV prostate cancer cannot be cured.

Loeb S, Eastham JA. Diagnosis and staging of prostate cancer. In: Partin AW, Dmochowski RR, Kavoussi LR, Peters CA, eds. Campbell-Walsh-Wein Urology. 12th ed. Philadelphia, PA: Elsevier; 2021:chap 152.

National Cancer Institute website. Prostate cancer screening (PDQ) - health professional version. www.cancer.gov/types/prostate/hp/prostate-screening-pdq. Updated May 22, 2023. Accessed July 24, 2023.

Reese AC. Clinical and pathologic staging of prostate cancer. Mydlo JH, Godec CJ, eds. Prostate Cancer. 2nd ed. Philadelphia, PA: Elsevier; 2016:chap 39.

Updated by: Kelly L. Stratton, MD, FACS, Associate Professor, Department of Urology, University of Oklahoma Health Sciences Center, Oklahoma City, OK. Also reviewed by David C. Dugdale, MD, Medical Director, Brenda Conaway, Editorial Director, and the A.D.A.M. Editorial team.