Treatment By Stage Of Prostate Cancer
Different treatments may be recommended for each stage of prostate cancer. Your doctor will recommend a specific treatment plan for you based on the cancers stage and other factors. Detailed descriptions of each type of treatment are provided earlier on this same page. Clinical trials may also be a treatment option for each stage.
Early-stage prostate cancer
Early-stage prostate cancer usually grows very slowly and may take years to cause any symptoms or other health problems, if it ever does at all. As a result, active surveillance or watchful waiting may be recommended. Radiation therapy or surgery may also be suggested, as well as treatment in clinical trials. For those with a higher Gleason score, the cancer may be faster growing, so radical prostatectomy and radiation therapy are often recommended. Your doctor will consider your age and general health before recommending a treatment plan.
ASCO, the American Urological Association, American Society of Radiation Oncology, and the Society of Urologic Oncology recommend that patients with high-risk early-stage prostate cancer that has not spread to other areas of the body should receive radical prostatectomy or radiation therapy with hormonal therapy as standard treatment options.
Locally advanced prostate cancer
Watchful waiting may be considered for older adults who are not expected to live for a long time and whose cancer is not causing symptoms or for those who have another, more serious illness.
What Does It Mean If In Addition To Cancer My Biopsy Report Also Says Acute Inflammation Or Chronic Inflammation
Inflammation of the prostate is called prostatitis. Most cases of prostatitis reported on a biopsy are not caused by infection and do not need to be treated. In some cases, inflammation may increase you PSA level, but it is not linked to prostate cancer. The finding of prostatitis on a biopsy of someone with cancer does not affect their prognosis or the way the cancer is treated.
How Prostate Cancer Is Diagnosed And Staged
Cancer staging helps you and your doctor understand how advanced your cancer is and how much it has spread at the time of diagnosis. Knowing your cancer stage also helps your doctor determine the best treatment options for you and estimate your chance of survival.
The most widely used staging system for cancer is the American Joint Committee on Cancers TNM system that classifies cancer from stage 1 to stage 4.
TNM stands for:
- Tumor: the size and extent of the tumor
- Nodes: the number or extent of nearby lymph node involvement
- Metastasis: whether cancer has spread to distant sites in the body
The TNM scale is used for many types of cancer. When a doctor uses it to determine your prostate cancer stage, theyll consider several other factors as well, including:
- grade groups
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The Prostate Cancer Grading System
Prostate cancer grading is based on the appearance of the tumor cells under the microscope. Low-grade cancer cells look more like healthy cells than do high-grade cells. The two methods used to measure prostate cancer grade are the Gleason score or Grade Group.
While examining the tumor cells, the pathologist looks at the two most common tumor cell patterns referred to as the primary and secondary patterns. Each of these patterns is then graded based on how closely they resemble normal prostate tissue.
Grade 1 cells look like normal prostate cells. Grade 5 cells are very abnormal appearing cells. Grades 2-4 are in between the higher the number, the less the cells look like normal prostate tissue. Almost all prostate cancer has grade 3 cells or higher. Once the pathologist has assigned a grade to the primary and secondary cell patterns, these two numbers are added together to get a total Gleason score. The higher the Gleason score, the more likely the tumor is going to grow or spread to other parts of the body. Since the lowest grade a cancer cell can have is grade 3 , the lowest Gleason score for a cancer is grade 6 and is considered low-grade prostate cancer.
Using the Gleason score, prostate cancers can be divided into three groups:
| Gleason Score | |
|---|---|
| Gleason score of 8-10 | high-grade prostate cancer |
ISUP Prostate Cancer Grade Groups:
| Grade group |
|---|
| advanced-grade cancer |
Can The Gleason Score On My Biopsy Really Tell What The Cancer Grade Is In The Entire Prostate
Because prostate biopsies are tissue samples from different areas of the prostate, the Gleason score on biopsy usually reflects your cancers true grade. However, in about 1 out of 5 cases the biopsy grade is lower than the true grade because the biopsy misses a higher grade area of the cancer. It can work the other way, too, with the true grade of the tumor being lower than what is seen on the biopsy.
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If Your Prostate Cancer Comes Back
If your cancer goes into remission but later returns, follow-up treatments will depend on where the cancer is located and which treatments youâve already tried.
- If the cancer is contained in your prostate, surgery or a second attempt at radiation is suggested. If youve had a radical prostatectomy, radiation therapy is a good option. If you had radiation, radical prostatectomy might be the best approach. Cryosurgery might also be an option.
- If the cancer has spread to other parts of your body, hormone therapy might be the most effective treatment. External or IV radiation therapy or bisphosphonate drugs can relieve your bone pain.
A New Perspective On Your Health
For many people, survivorship serves as a strong motivator to make lifestyle changes.
People recovering from prostate cancer are encouraged to follow established guidelines for good health, such as not smoking, limiting alcohol, eating well, maintaining a healthy weight, and managing stress. Regular physical activity can help rebuild your strength and energy level. Your health care team can help you create an appropriate exercise plan based upon your needs, physical abilities, and fitness level. Learn more about making healthy lifestyle choices.
It is important to have recommended medical checkups and tests to take care of your health.
Talk with your health care team to develop a survivorship care plan that is best for your needs.
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Active Surveillance In Intermediate
Active surveillance is generally recognized as the preferred option for men with low-risk prostate cancer. Current guidelines use prostate-specific antigen of 10-20ng/mL or low-volume biopsy Gleason grade group 2 as features that, in part, define the favorable intermediate-risk disease and suggest that AS may be considered for some men in this risk category.
We identified 26,548 men initially managed with AS aged < 80 years, with clinically localized prostate cancer , PSA20ng/mL, biopsy GG2 with percent positive cores 33% and who converted to treatment with radical prostatectomy from the surveillance, epidemiology, and end results prostate with the watchful waiting database. Multivariable logistic regression was performed to determine predictors of adverse pathology at RP according to PSA level and GG .
Of 1731 men with GG 1 disease and PSA 10-20ng/mL, 382 harbored adverse pathology compared to 2340 of 8,367 men with GG 2 and a PSA< 10ng/mL who had adverse pathology at RP. On multivariable analysis, the odds of harboring adverse pathology with a PSA 10-20ng/mL was less than that of GG 2 after adjustment.
Our results support extending AS criteria more permissively to carefully selected men with PSA 10-20ng/mL and GG 1 disease.
Prostate cancer and prostatic diseases. 2021 Sep 10
Peter E Lonergan, Chang Wook Jeong, Samuel L Washington, Annika Herlemann, Scarlett L Gomez, Peter R Carroll, Matthew R Cooperberg
What Is A Gleason Score
Cancer cells donât look the same as healthy cells. The more different they appear, the more aggressive the cancer tends to be.
The Gleason system uses the numbers 1 to 5 to grade the most common and second most common patterns of cells found in a tissue sample.
- Grade 1: The tissue looks very much like normal prostate cells.
- Grades 2-4: Cells that score lower look closest to normal and represent a less aggressive cancer. Those that score higher look the furthest from normal and will probably grow faster.
- Grade 5: Most cells look very different from normal.
Doctors add your primary and secondary numbers together to form your total Gleason score. That tells you how aggressive the cancer is. The lowest score for a cancer is 6, which is a low-grade cancer. A Gleason score of 7 is a medium-grade cancer, and a score of 8, 9, or 10 is a high-grade cancer.
Generally speaking, the higher your Gleason score, the more aggressive the cancer. That means itâs more likely to grow and spread to other parts of your body. Doctors use this information, along with the stage of the cancer, to choose the best treatment for you.
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The Ajcc Tnm Staging System
A staging system is a standard way for the cancer care team to describe how far a cancer has spread. The most widely used staging system for prostate cancer is the AJCC TNM system, which was most recently updated in 2018.
The TNM system for prostate cancer is based on 5 key pieces of information:
- The extent of the main tumor *
- Whether the cancer has spread to nearby lymph nodes
- Whether the cancer has spread to other parts of the body
- The PSA level at the time of diagnosis
- The Grade Group , which is a measure of how likely the cancer is to grow and spread quickly. This is determined by the results of the prostate biopsy .
*There are 2 types of T categories for prostate cancer:
- The clinical T category is your doctors best estimate of the extent of your disease, based on the results of the physical exam and prostate biopsy, and any imaging tests you have had.
- If you have surgery to remove your prostate, your doctors can also determine the pathologic T category . The pathologic T is likely to be more accurate than the clinical T, as it is done after all of your prostate has been examined in the lab.
Numbers or letters after T, N, and M provide more details about each of these factors. Higher numbers mean the cancer is more advanced. Once the T, N, and M categories have been determined, this information is combined in a process called stage grouping to get the overall stage of the 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 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.
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Proposal For A New Grading System
Although Gleason scores range from 2 to 10, there are 25 potential scores . If one were coming up with a new grading system starting from scratch one would want to distill it down to a simple system with the least number of grades, each with their distinct prognosis. Based on a series of 6462 men treated by RP where both the needle biopsy and RP were graded using the current modified Gleason grading system, this author showed both for biopsy and for RP that the following Gleason grade groups accurately reflects prognosis: Gleason score 26 Gleason score 3+4=7 Gleason score 4+3=7 Gleason score 8 and Gleason scores 910 .
In a recent meta-analysis of over 20000 men treated by RP from five institutions, Grade Groups were strongly correlated with risk of biochemical recurrence after surgery. Assigning a risk of 1 to Gleason score 6, the relative risks of progression for Grade Groups 25 were 2.6, 8.5, 16.8, and 29.3. The 5-year biochemical risk-free survival was 97.5%, 93.1%, 78.1%, 63.6%, and 48.9% for Grade Groups 15, respectively. These grade grouping was also validated on biopsy correlating with risk of progression after RP and following radiation therapy. Following these initial studies, there have been numerous works that have validated the new grading system following RP and radiation therapy, including its correlation with prostate cancer death and distant metastases., , , , , , , , ,
Table 1 Definition of Grade Groups
What Does It Mean
A Gleason score of 6 is low grade, 7 is intermediate grade, and a score of 8 to 10 is high grade cancer.
Get More Information
Its also important to know whether any cells rated at Gleason grade 5 are present, even in just a small amount, and most pathologists will report this. Having any Gleason grade 5 in your biopsy or prostate puts you at a higher risk of recurrence.
But because many prostate cancer cases are extremely slow-growing, the Gleason system didnt necessarily do a good job of communicating the risks for these cases. Patients with scores of 6 and 7 didnt have a clear picture of the nature of their particular cancer.
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Tertiary Grade On Needle Core Biopsy
In contrast to the original Gleason grading system, it is now recommended that on a needle core biopsy both the most common and highest grade are added together for the Gleason score . For example, if there is 60 % Gleason pattern 3, 35 % Gleason pattern 4, and 5 % Gleason pattern 5, the Gleason score would be 3+5=8. Needle core biopsy is an imperfect, non-targeted, random sampling of the prostate gland. Thus any amount of high-grade tumor sampled on needle biopsy most likely indicates a more significant amount of high-grade tumor within the prostate. In all specimens, in the setting of high-grade cancer, one should not report a lower grade if it occupies less than 5 % of the total tumor. For example, if there is 98 % Gleason pattern 4 and 2 % Gleason pattern 3, the Gleason score would be reported as 4+4=8 .
The Grade Group And Psa Level Are Used To Stage Prostate Cancer
The stage of the cancer is based on the results of the staging and diagnostic tests, including the prostate-specific antigen test and the Grade Group. The tissue samples removed during the biopsy are used to find out the Gleason score. The Gleason score ranges from 2 to 10 and describes how different the cancer cells look from normal cells under a microscope and how likely it is that the tumor will spread. The lower the number, the more cancer cells look like normal cells and are likely to grow and spread slowly.
The Grade Group depends on the Gleason score. See the General Information section for more information about the Gleason score.
- Grade Group 1 is a Gleason score of 6 or less.
- Grade Group 2 or 3 is a Gleason score of 7.
- Grade Group 4 is a Gleason score 8.
- Grade Group 5 is a Gleason score of 9 or 10.
The PSA test measures the level of PSA in the blood. PSA is a substance made by the prostate that may be found in an increased amount in the blood of men who have prostate cancer.
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Prostate Cancer Staging: Stage Grouping
One of the most important things to consider when determining treatment is your prostate cancer stage. Once, your healthcare provider has determined the TNM stage, he or she will then combine that information with the PSA level and Gleason Grade Group to get your stage group. AJCC Stage Groups are numbered I-IV , with higher numbers meaning more advanced disease. They can also be subdivided into smaller groups, indicated by letters , with C being the more advanced disease.
| AJCC stage |
|---|
| PSA can be any value |
Understanding Your Pathology Report: Prostate Cancer
When your prostate was biopsied, the samples taken were studied under the microscope by a specialized doctor with many years of training called a pathologist. The pathologist sends your doctor a report that gives a diagnosis for each sample taken. Information in this report will be used to help manage your care. The questions and answers that follow are meant to help you understand medical language you might find in the pathology report from your prostate biopsy.
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What Is The Prostate Cancer Gleason Score
If your doctor recommends a prostate biopsy, your pathology report will include a prostate cancer Gleason score. Doctors typically take several samples during the biopsy and each sample will have its own grade. Cell samples are graded from one to five a grade five means the cells have mutated and no longer resemble normal cells.
A pathologist will assign one grade to the most predominant cell pattern in your biopsy samples, and a second grade to your second most predominant cell pattern. When these results are presented on your pathology report, however, they are added together, which may be confusing.
For example, you may see 3+4=7 or 4+3=7 on your pathology report. The first number in the equation indicates the predominant cell pattern in your tumor. If you see a 4+3=7 on your report, it means your cancer is more advanced than a 3+4=7. This distinction is very important for understanding the severity of your tumor. To help people better understand their prostate cancer Gleason score grade groups were developed.