How Doctors Use Risk Assessing System To Determine Best Prostate Cancer Treatment Approach

Understanding TNM Staging for Prostate Cancer

T: Tumor. This refers to the size and extent of the primary tumor within the prostate.

• T1 tumors are not detectable through imaging or physical exam, and are only found via biopsy.
• T2 tumors are confined to the prostate but can be felt during a digital rectal exam or seen via imaging.
• T3 tumors extend beyond the prostate capsule, possibly affecting the seminal vesicles.
• T4 tumors have spread to nearby tissues such as the bladder or rectum.

N: Nodes. This indicates whether the cancer has spread to nearby lymph nodes.

• N0 means no spread to lymph nodes.
• N1 indicates that cancer has spread to nearby lymph nodes.

M: Metastasis. This evaluates whether the cancer has spread (metastasized) to distant parts of the body.

• M0 means no distant spread.
• M1 means there is distant metastasis (e.g., bones, lungs, liver).

The combination of these factors gives a clear picture of how advanced the cancer is, which directly affects risk stratification and treatment options.

What Is The Gleason Score?

The Gleason Score is a grading system used to evaluate the aggressiveness of prostate cancer based on biopsy results. It examines how much the cancer cells differ from normal prostate cells under a microscope. The more abnormal the cells, the more aggressive the cancer.

Two grades are assigned, each ranging from 1 to 5 — one for the most common cell pattern seen, and the other for the second most common pattern. These two numbers are added together to give the Gleason Score, which ranges from 6 to 10.

The scores are usually grouped into Grade Groups:

• Grade Group 1 (Gleason 6): Low-grade cancer
• Grade Group 2 (Gleason 3+4=7): Favorable intermediate risk
• Grade Group 3 (Gleason 4+3=7): Unfavorable intermediate risk
• Grade Group 4 (Gleason 8): High-grade cancer
• Grade Group 5 (Gleason 9-10): Very high-grade, aggressive cancer

Higher Gleason Scores typically indicate more aggressive cancers that are more likely to spread quickly.

How Does PSA Affect Your Risk?

Prostate-specific antigen (PSA) is a protein produced by prostate cells. PSA is measured through a blood test and is one of the first signs that something might be wrong with the prostate.

Normal PSA levels vary with age, but in general:

• A PSA under 4 ng/mL is considered normal for most men
• A PSA between 4-10 ng/mL is a gray zone
• PSA above 10 ng/mL increases the concern for prostate cancer, especially if it rises rapidly over time

Elevated PSA levels alone do not confirm cancer, but they can indicate an increased risk and often lead to further testing. When used in conjunction with TNM staging and Gleason Score, PSA levels help define a patient’s risk category.

What Are The Risk Categories?

The National Comprehensive Cancer Network (NCCN) and other leading organizations define prostate cancer risk categories using a combination of PSA, TNM stage, and Gleason Score.

• Low Risk: PSA <10 ng/mL, Gleason Score 6 (Grade Group 1), tumor confined to the prostate (T1-T2a)
• Intermediate Risk: PSA 10–20 ng/mL, Gleason Score 7 (Grade Group 2 or 3), tumor extending further within the prostate (T2b or T2c)
• High Risk: PSA >20 ng/mL, Gleason Score 8–10 (Grade Group 4 or 5), tumor has spread beyond the prostate (T3a or higher)
• Very High or Advanced Risk: T3b-T4 tumors, multiple high-grade features, regional lymph node involvement (N1) or distant metastasis (M1)

Treatment Options Based On Risk

Treatment options for prostate cancer range from active surveillance, or a watchful waiting approach, to a combination of multiple innovative and powerful therapies.

“For patients who are low risk, the preference is active surveillance, meaning these patients can be monitored with PSAs, potentially re-biopsies — because the risk of metastasis or complications is very, very low,” Dr. Dal Pra explains. “For patients with intermediate risk prostate cancer, it can be treated either with surgery or radiation therapy — with or without short-term hormonal therapy.

“For high-risk, non-metastatic disease, we also have the option of radiation, usually combined with long-term hormonal therapy (about 2 years), or surgery, often followed by radiation if there is a biochemical recurrence,” he adds.

Here is a break down of treatment options based on risk:

Low-Risk Patients

• Active Surveillance: The most common approach involves regular PSA testing, digital rectal exams, and repeat biopsies to monitor for progression.
• Surgery or Radiation Therapy: These may be considered for younger patients or those anxious about delaying treatment.

Intermediate-Risk Patients

• Radiation Therapy: This is often combined with short-term androgen deprivation therapy (ADT).
• Radical Prostatectomy: The surgical removal of the prostate, which can sometimes include lymph node dissection.
• Active Surveillance: This may be an option for favorable intermediate-risk cases, especially in older patients.

High-Risk Patients

• Radiation + Long-Term ADT: This combination is often the first choice, typically with 18-36 months of hormone therapy.
• Radical Prostatectomy: This approach is considered in some cases, often followed by radiation or hormone therapy depending on pathology.
• Clinical Trials: Experimental trials may be recommended for access to newer treatments.

Very High/Advanced Risk Patients

• Systemic Therapies: These may include hormone therapy, chemotherapy, or newer agents like androgen receptor inhibitors.
• Palliative Treatments: This approach focuses on managing symptoms and maintaining quality of life if cure is no longer possible.

Questions To Ask Your Doctor

• What is my risk level?
• What are the treatment options for my risk level?
• What are the risks vs. benefits of these approaches?
• How will we monitor my risk level?
• What are my options if my risk level changes?

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