Grading and staging
for
advanced prostate
cancer (aPC)

The grade and stage of prostate cancer can help stratify risk

Conduct risk stratification to optimize patient care

Risk stratification includes1,2:
  • Assessing prostate-specific antigen (PSA) levels
  • Grade of the tumor
  • Extent of the cancer revealed by biopsy
  • Stage of cancer
  • Spread of cancer
PSA blood test3,4

PSA tests can reveal recurrence and give an indication of the cancer’s growth.

A healthcare professional prepares to draw blood from a seated man’s arm with sunlight coming through a window.

Consider the value of the PSA along with the patient’s age and size of prostate, as a larger prostate could yield a higher PSA value. Calculate the PSA density (PSAD) by dividing PSA level by prostate volume. A value of ≥0.15 may require further evaluation.  

Tumor grade

Different techniques can be used to help determine risk scores of prostate cancer.
The Gleason score can predict how aggressive the cancer is based on how normal or abnormal biopsied cells appear under a microscope or by pathological examination. An example of cell types seen in Gleason patterns 1 to 5 are reflected below5: 

1

Small, identical cells that are close together

2

Cells in various shapes and sizes, loosely packed

3

Increased cell size with irregular shapes; cells
are closer together

4

Large, irregular, fused cells

5

Irregular, fused cells that have invaded
surrounding connective tissue cells
Drawn diagram showing normal and abnormal cells according to Gleason scoring.
Drawn diagram showing normal and abnormal cells according to Gleason scoring.

Gleason score is determined by grading the two most common cell types (Gleason patterns) found during biopsy. These are then added together for a score. Scores range from 6-10, with 6 being more normal and low risk and 10 being very abnormal and higher risk.5

The grade group system uses numbers from 1-5 to grade tumors, with 1 being more normal and low risk and 5 being very abnormal and higher risk.2,6

See how to stratify risk for prostate cancer based on certain criteria by reviewing the accompanying table.

Prostate cancer risk stratification7*
Risk ProfileCriteria†
Favorable: very low riskT1c, Gleason score ≤6, PSA level <10 ng/mL, PSA density <0.15 ng/mL/mL, <3 biopsy cores positive, ≤50% cancer in any core
Low riskT1 or T2a, Gleason score 2-6, PSA level <10 ng/mL
IntermediateT2b - T2c or Gleason score 7 or PSA level 10-20 ng/mL
HighT3a or Gleason score 8-10 or PSA level >20 ng/mL

*Adapted from: D’Amico et al. and Epstein et al.

†Adapted from: Mohler J et al. and based on T-stage, Gleason score, PSA level, PSA density, number and percentage of biopsy cores with cancer.

12-core systematic biopsy8
Determined by taking the number of biopsy needle cores containing cancer and dividing by the total number of cores sampled. The higher the fraction of positive cores, the more pervasive the disease may be.
Tumor, nodes, metastasis (TNM) system9
The TNM system is a staging method created by the American Joint Committee on Cancer (AJCC) and the Union for International Cancer Control (UICC).

The TNM system uses numerical values to classify the extent of the primary tumor (T category), whether the cancer has spread to nearby lymph nodes (N category), and if the cancer has metastasized (M category).

Expand the accordion below for detailed TNM definitions and classifications.

ClassificationDefinition
Tumor
TxTumor cannot be evaluated (due to lack of information)
T0No evidence of a primary tumor
T1Tumor 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)
T1aTumor incidental histologic finding in 5% or less of tissue resected
T1bTumor incidental histologic finding in more than 5% of tissue resected
T1cTumor identified by needle biopsy found in one or both sides, but not palpable
T2Tumor can be detected during a DRE but is present in the prostate only
T2aTumor is in half or less than one side (lobe) of the prostate
T2bTumor is in more than half of one prostate lobe, but has not yet invaded the other lobe
T2cTumor is in both prostate lobes
T3Tumor extends outside of the prostate
T3aTumor extends outside of the prostate on one or both sides or microscopic invasion of bladder neck
T3bTumor has spread to the seminal vesicles (the glands on each side of the bladder)
T4Tumor has spread to tissues near the prostate other than the seminal vesicles, such as the bladder, external sphincter, rectum, levator muscles, and/or wall of the pelvis 
Nearby (regional) lymph nodes (N)
NxNearby lymph nodes are not evaluated
N0No cancer cells are found in nearby lymph nodes
N1Cancer cells are found in nearby lymph nodes
Distant metastasis (M)
M0Cancer has not yet spread beyond the prostate
M1Cancer has spread beyond the prostate
M1aCancer has spread to distant lymph nodes
M1bCancer has spread to bone
M1cCancer has spread to another organ or site, with or without bone disease
Classification 
Definition 
Tumor
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) 
T1a
Tumor incidental histologic finding in 5%or less of tissue resected 
T1b
Tumor incidental histologic finding in more than 5% of tissue resected 
T1c
Tumor identified by needle biopsy found in one or both sides, but not palpable 
T2
Tumor can be detected during
a DRE but is present in the
prostate only
T2a
Tumor is in half or
less than one side
(lobe) of the prostate 
T2b
Tumor is in more than
half of one prostate
lobe, but has not yet
invaded the other lobe 
T2c
Tumor is in both
prostate lobes
T3
Tumor extends outside of the
prostate 
T3a
Tumor extends outside
of the prostate on one
or both sides or microscopic invasion of bladder neck 
T3b
Tumor has spread to
the 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, external sphincter, rectum, levator muscles, and/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 
Cancer has not yet spread beyond the prostate 
M1
Cancer has spread beyond
the prostate 
M1a
Cancer has spread to
M1b distant lymph nodes 
M1b
Cancer has spread
to bone 
M1c
Cancer has spread to
another organ or site,
with or without bone
disease 

The TNM score can then be used in addition to the PSA value and Gleason score to determine the cancer stage.

Evaluating for metastatic disease

The likelihood of metastatic disease is based on PSA value, Gleason score or grade group, and staging. For example, a high PSA (i.e., 200), Gleason score 8-10, or T3-T4 suggests an aggressive cancer and warrants sensitive imaging to determine presence or extent of metastasis.

gray-icoon

Patients with advanced prostate cancer are already in stage 3 or 4 of disease8​

Diagnosing, Grading, and Staging aPC

Diagnosing, Grading, and Staging aPC

Download a printable quick-reference guide about diagnosing, grading, and staging advanced prostate cancer that you can use in-office.
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