Prostate cancer originates from the prostate gland, a walnut-shaped organ in males that produces a seminal fluid that nourishes and transports sperm. The exact causes of prostate cancer are still unknown, but the most common risk factor is age. Prostate cancer is often diagnosed in men aged 50 and above.
There are a variety of prostate cancer treatments, and their suitability depends on the nature of each case. In this blog, we will discuss how prostate cancer treatments are categorised as per stage and risk groups.
Prostate cancer staging
Cancer staging is a method to determine the phase of prostate cancer. Prostate cancer staging involves examining test results to find out if the cancer has spread to other parts of the body beyond the prostate gland. Staging is important to determine the extent of cancer, to look for suitable treatments and to analyse a patient’s prognosis or likelihood of recovery.
There are two types of prostate cancer staging: clinical and pathological.
No matter the type of staging used, doctors use the TNM staging system, and gleason score and PSA levels to describe the nature of prostate cancer. It also helps in deciding the line of treatment as well as assessing the prognosis for the patient.
1. TNM staging
Prostate cancer specialists use a tool called the TNM system to describe the stage of cancer. This system, created by the American Joint Committee on Cancer, helps answer important questions:
- Tumour (T): How big is the main tumour, and where is it?
- Node (N): Has the tumour spread to lymph nodes? If yes, where and how many?
- Metastasis (M): Has cancer spread to other body parts? If yes, where and how much?
Combining these results gives the cancer stage, ranging from stage 0 (zero) to stages I through IV (1 through 4). Staging helps doctors describe cancer consistently, allowing them to plan the best treatments together.
| Primary tumour (T) Clinical (cT) | |
| TX | Primary tumours cannot be assessed. |
| T0 | No evidence of the primary tumour. |
| T1 | Clinically inappropriate tumour not palpable or visible by imaging. |
| T1a | Incidental histologic finding in ≤5% of resected tissue. |
| T1b | Incidental histologic finding in >5% of resected tissue. |
| T1c | Tumour identified by needle biopsy (due to elevated PSA). |
| T2 | Tumour confined within the prostate. |
| T2a | Involves one-half of 1 lobe or less. |
| T2b | Involves over half of a single lobe without affecting both lobes |
| T2c | Involves both lobes. |
| T3 | The Tumour extends through the prostatic capsule. |
| T3a | Extracapsular extension. |
| T3b | Tumour invades seminal vesicle(s). |
| T4 | Tumour fixes or invaded adjacent structures. |
Regional lymph nodes (N): | |
Clinical (cN) | |
| NX | Regional lymph nodes not assessed. |
| N0 | No regional lymph node metastasis. |
| N1 | Metastasis in regional lymph nodes(s). |
Pathologic (pN) | |
| pNX | Regional nodes not sampled. |
| pN0 | No positive regional nodes. |
| pN1 | Metastases in regional nodes(s). |
Distant metastasis (M)* | |
| M0 | No distant metastasis. |
| M1 | Distant metastasis. |
| M1a | Non Regional lymph nodes(s). |
| M1b | Bone(s). |
| M1c | Other site(s) with or without bone disease. |
2. Gleason Score Grading
The Gleason score assesses how much prostate cancer cells resemble healthy tissue under a microscope. Less aggressive tumours resemble healthy cells, while more aggressive ones look different from healthy tissue and are likely to spread. The pathologist assigns scores from 3 to 5 based on cell appearance in two different locations, once where the growth is apparent and another where it isn’t. Cancer cells bearing similarity to healthy cells get a low score, while those looking different are given a higher score. The total score falls between 6 and 10. Scores below 6 are not used; 6 is low-grade; 7 is medium-grade; and 8-10 are high-grade, indicating varying growth and spreading likelihoods. Based on the Gleason score, doctors may recommend prostate cancer treatment.
Treatment Options According to Stages
Stage 1 prostate cancer treatment
- Stage 1 corresponds with cT1-T2a, pT2, N0 and M0, and Gleason less than 6 and PSA less than 10. It is characterised by slow-growing cancer, and treatment options include active surveillance, involving regular monitoring with PSA tests and digital rectal exams (DREs).
- Watchful waiting or observation is suitable for those with a limited lifespan due to other health issues.
- Surgery and radiation therapy, either through external beam or brachytherapy, are also choices for those who want treatment, but it is important to note that these may have potential side effects.
Stage 2 prostate cancer treatment
- In Stage 2, cT1c-T2a-cT2b, N0, M0, and cT2a-cT2b-cT2c, Gleason score 6-8, and PSA less than 20. The cancer is confined to the prostate, treatment options vary based on the substage (2A, 2B, 2C).
- For low-risk cases, active surveillance is recommended. This involves regular monitoring. Observation is a suitable option for those with serious health issues.
- Aggressive treatment like radiation therapy or surgery may be advised for low-risk individuals with other medical concerns and a preference for immediate treatment.
Stage 3 prostate cancer treatment
- Stage 3, T1, T2, N0, M0, Gleason 8-10 and any PSA. The treatment options vary based on the substage (3A, 3B, 3C).
- Radiation therapy is advised. It is often combined with a pelvic lymph node dissection.
- Surgical removal, or radical prostatectomy, is also considered as an option.
- Active surveillance is also a choice in some cases, but it comes with a slightly higher risk of cancer spread.
- Watchful waiting is recommended for those who do not have many years to live or have other serious illnesses.
Stage 4 prostate cancer treatment
- Stage 4, any T, any N and M0 or M1, any PSA, are advanced and no longer confined to the prostate. Aggressive therapy is recommended depending on the extent of spread; there is, however, no cure for metastatic prostate cancer, but doctors may combine a variety of treatments to extend life and outlive the disease.
- For 4A, treatment may involve addressing lymph nodes in the region. For 4B, treatment extends to distant lymph nodes and possibly bones. Combination therapies, such as chemotherapy, immunotherapy, or targeted therapy, are considered.
- Clinical trials are also advised in many cases.
- Palliative care is advised to focus on symptom relief and improving the quality of life.
Risk Groups and Initial Prostate Cancer Treatment
While cancer staging has its benefits, doctors also use the prostate cancer risk groups as a classification to understand the likelihood of disease progression and guide treatment decisions, especially for Stages 1, 2, and 3 of prostate cancer. The risk groups for stage 1 to stage 3 prostate cancers include:
- Very low-risk group:
- PSA level is less than 10 ng/mL
- Gleason score is below 6
- The cancer is within the prostate (cT1c)
- Treatment advice: active surveillance, or radiation and surgery (if preferred by the patient).
- Low-risk group:
- PSA level is usually less than 10 ng/mL.
- Gleason score is 6 or lower.
- The cancer is confined to the prostate (T1-T2a).
- Treatment advice: active surveillance, observation, or in some cases radiation, surgery along with hormone therapy (if the patient prefers it).
- Favourable Intermediate-risk group:
- PSA levels are between 10 and 20 ng/mL.
- Gleason’s score is 7.
- The cancer may extend slightly beyond the prostate (T2b) or involve one lobe completely (T2c).
- Treatment advice: active surveillance, surgery, radition therapy or hormone therapy.
For unfavourable intermediate-risk groups, treatment advice includes surgery, external radiation therapy with hormone therapy or brachytherapy.
- High-risk group:
- PSA levels are typically higher than 20 ng/mL.
- Gleason score is 8-10.
- The cancer has a high risk of extending beyond the prostate (T3a), or invading the seminal vesicles (T3b), or involving nearby structures (T4).
- Very high-risk group:
- PSA levels over 20 ng/mL
- Gleason score between 8 and 10
- The tumour is categorized as (T3b)
For high and very high risk groups, radiation therapy, along with hormone therapy or surgery are advised.
Risk groups are helpful, but they are not perfect at predicting if prostate cancer will come back or how aggressive it might be. Discuss the benefits and risks of treatments with your doctor.
Conclusion
Treatment options for prostate cancer are varied, each carrying its own risks and benefits. Apart from the staging and risk groups, prostate cancer specialists take into account various other considerations, such as side effects, patients’ preferences and life span, and financial considerations, for advising prostate cancer treatment. Discuss the most appropriate treatment for your case before making any decisions.
Disclaimer:
This article has been written for information purposes only, and is not a substitute for professional medical advice by a qualified doctor or other health care professional. The author is not responsible or liable, directly or indirectly, for any form of damages whatsoever resulting from the use (or misuse) of information contained in or implied by the information in this article. Always consult a qualified healthcare provider for accurate diagnosis, personalised treatment, and recommendations tailored to your individual health needs.