Grading and Staging of Prostate Cancer

As with all types of cancer, patients with prostate cancer are evaluated based on several parameters, including the grade and stage of their disease. Grading of disease, also known as the Gleason grade, determines the aggressiveness of the cancer cells. The stage of disease determines whether the cancer is still limited to the prostate or if there has been progression within or even outside the prostate. The combination of these two factors is very important in determining a patient’s curability, likelihood of response to treatment options, long-term outcomes, and determining which treatment option (whole gland therapy, surgery, radiation therapy, brachytherapy, HIFU, hormonal therapy, or alternative therapies) is ideal for a patient.

At the Prostate Cancer Institute of LA, our team of expert urologists can identify, diagnose, and treat prostate cancer in any stage. However, like other forms of cancer, early identification is critical for successful treatment. To schedule a consultation, please contact the Prostate Cancer Institute of LA today.

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Methods of Grading and Staging Prostate Cancer

In order to determine the grade and stage of prostate cancer, our expert urologists will perform a number of tests. These typically include one or a combination of the following:

Prostate-Specific Antigent (PSA)

The prostate gland produces a specific protein or antigen that can be detected in a man’s blood. In many cases, elevated levels of PSA in the blood may indicate the presence of prostate cancer or other benign prostate conditions, such as prostatitis or benign prostatic hyperplasia. PSA screening tests are typically followed with additional tests, depending on the results. A high PSA level does not automatically mean that a patient has cancer or a prostate condition.

Digital Rectal Exam (DRE)

The physician or urologist will physically feel for any irregularities in the size, shape, and texture of a man’s prostate by simply inserting a gloved and lubricated finger into the rectum. Experienced urologists can perform the DRE to determine whether the patient is likely to have prostate cancer or a non-cancerous condition.

Men typically receive a PSA and/or DRE on a regular basis at the age of 50 as a precautionary measure.

Magnetic Resonance Imaging (MRI)

Using a special sequence, referred to as a multi-parametric MRI, MRIs can identify the location and extent of cancers in the prostate. Prostate MRIs are valuable studies that help our urologists perform more accurate prostate biopsies, and more accurately diagnose men at risk of having cancer. The cancer imaging ability of MRIs also help our prostate cancer specialists determine the best types of treatments for men with prostate cancer, including focal therapy (using HIFU) and whole gland therapies (robotic surgery, radiation therapy and HIFU).

APIFINY Blood Test

The APIFINY is a non-PSA blood test that measures specific biological markers that exist in the bloodstream as a result of the patient’s immune system response to prostate cancer. The test can provide additional information for our urologists to assess when determining whether a patient has prostate cancer and whether further treatment is necessary.

The APIFINY test requires only a simple blood sample, which is evaluated by an outside laboratory and assigned a score depending on the patient’s risk level.

Genetics Testing

Genetics testing is the latest method for ruling out whether a patient has the genetic biomarkers of prostate cancer. In many cases, high-risk men may undergo repeat biopsies to confirm whether or not they have cancer, which can put a patient through unnecessary pain and eventual loss of quality of life. Genetics tests can detect chemical alterations in the gene sequence of prostate tissue that is taken during a single biopsy. The presence of this chemical alteration in the genes is typically a strong indicator of cancer.

Grades of Prostate Carcinoma

To determine the severity of a patient’s prostate cancer, doctors utilize a grading system on a 1-5 scale. Grading is performed on a tissue sample from the prostate (after a targeted prostate biopsy has been performed, for example). The cancer glands are then graded based on their aggressiveness.

  • Grade 1: The lowest grade of prostate cancer. In grade 1 prostate cases, the removed prostate tissue looks almost identical to normal prostate tissue, indicating that the cancer’s growth is slow.
  • Grades 2-3: In these grades, the glands begin to look abnormal and portend a moderate degree of aggressiveness.
  • Grade 4: In grade 4, the glands appear more aggressive as the cancer is no longer forming a glandular architecture. Additionally, some of the cells are leaving the glands and invading the connective tissue around the glands. Grade 4 cancers are moderate to high-grade cancers
  • Grade 5: The most severe of the grades. Grade 5 cancers are highly aggressive and the cells are no longer creating gland-like patterns. Instead, they are mainly in single cell formation, invading the connective tissue of the prostate.

Gleason Score

The ultimate Gleason score is determined by adding the grade of the most dominant type of cancer identified in the cancer tissue (grades 1-5)  to the grade of the second-most predominant cancer type (grade 1-5). The final Gleason score therefore ranges from 2-10.

  • Gleason scores of 2-4: are the least-aggressive cancers,
  • Gleason scores of 5 and 6 are moderately-aggressive cancers
  • Gleason score of 7 is a moderate to highly-aggressive cancer
  • Gleason scores of 8-10 are highly-aggressive cancers.

The higher the grade and Gleason score, the more likely it is for the cancer cells to rapidly grow and metastasize. If left untreated, prostate cancers can spread through local extension (into the bladder), through the lymph system (to the lymph nodes), or through the blood stream (to the bones and other organs).

Stages of Prostate Carcinoma

Prostate cancer staging refers to how much the cancer has spread. Prostate cancers are divided in to four stages based on the level of progression. Identifying the stage of the cancer is key in determining the best treatment options for a patient.

Stage I Cancer

Stage I is the first level of prostate cancer staging. In this level, cancer is found within the prostate only, and the cancer has not spread to any neighboring regions of the body. The majority of these cancers are small enough that they are not noted on a rectal exam and instead are often identified on the PSA blood test (prostate cancer screening blood test), or a perfusion dynamic MRI of the prostate followed by MRI fusion biopsies.

Patients with Stage I prostate cancer can be ideal candidates for focal therapy.

Stage II Cancer

In stage II, the prostate cancer has grown to the extent that it has become palpable on a digital rectal exam performed by a physician. Though the cancer is more advanced than stage I cancer, it is still contained within the prostate.

Stage II prostate carcinoma is divided into two subcategories. The first form of stage II cancer is called stage IIA. In stage IIA the cancer is palpable but only limited to less than one lobe of the prostate. The second stage, stage IIB, involves cancer within both lobes of the prostate. Some patients with stage II prostate cancer can still be candidates for focal prostate cancer therapy

Stage III cancer

Stage III is the first stage in which the cancer has spread to tissues outside of the prostate. In many cases, the cancer spreads to the nearby seminal vesicles, which are located close to the prostate and are partially responsible for the production of seminal fluid. Alternatively, the cancer has grown into the connective tissue just outside the prostate. As with Stage IV cancers, once the cancer has grown outside the prostate itself, there is a higher chance that the cancers cells can metastasize to other parts of the body via the lymph system or blood stream.

Stage IV cancer

Stage IV prostate cancer is the most serious form of the disease. In stage IV, cancer has spread beyond the prostate and has invaded other tissues and organs like the rectum and bladder. In addition, cancer at this stage may have traveled to further parts of the body through the lymph system or the blood stream.

Treatment Options for Prostate Cancer Stages

Treatment options for patients with prostate cancer include:

  • Active surveillance
  • Robotic prostatectomy (surgery)
  • TrueBeam IMRT (radiation therapy)
  • Brachytherapy
  • High-intensity focused ultrasound
  • Cryotherapy
  • Hormonal therapy
  • Chemotherapy

Determining the ideal treatment option for a patient depends on several variables including:

  • The patient’s desires and priorities
  • The patient’s state of health
  • The patient’s age
  • The grade of the cancer
  • The stage of the cancer
  • The patient’s PSA level
  • Findings on physical examination

By in large, patients who have early-stage disease have undergone either active surveillance, surgery, or radiation therapy to treat their disease. However, because of improvements in prostate cancer imaging and mapping, many patients with early stage disease are now candidates for focal therapy (whereby only the diseased segment of the prostate is treated and the healthy portions of the prostate are preserved).

Patients with more advanced stages of prostate cancer typically undergo treatment with hormonal and or chemotherapy. These treatment modalities are sometimes combined with radiation therapy as well. Though prostate cancer in its later stages cannot be fully cured, these treatment options are designed to contain, monitor, and curtail further progression of the cancer.

The Prostate Cancer Institute of LA will identify which treatment options are most suitable for a patient.

Targeted Biopsies

Using state of the art technology, targeted biopsies, such as an MRI fusion image-guided biopsy, allow for physicians to visualize and track the prostate with a 3D model. Through a combination of an ultrasound and MRI technology, surgeons can find and track suspicious or abnormal areas of the prostate in real-time. Thanks to this new technology, prostate cancer diagnosis is more accurate and effective than ever before.

Focal Therapy

Instead of pursuing an active-surveillance approach to early stages of prostate cancer, some patients may want to eliminate the cancer completely. Focal therapy is a treatment that destroys specific areas of the prostate while leaving the healthy prostate cells alive and intact. Factors in determining the efficiency of this treatment include the size of the cancer and prostate, the location of the cancer, a patient’s PSA levels, and more.

da Vinci Robotic Prostatectomy

With the da Vinci robotic system, prostatectomies (removal of the prostate) are performed using several small incisions as opposed to a single large one. The system itself uses high-tech 3D cameras and special instruments to perform the procedure with more precision and dexterity than ever before.

The benefits of a da Vinci prostatectomy over a traditional prostatectomy are numerous. The entire operation is more precise, there are less post-surgical complications, recovery time is faster, the procedure is performed faster, there is less pain, and more. At the Prostate Cancer Institute of LA, our specialists are experts in performing a da Vinci prostatectomy.

IMRT (TrueBeam) Radiation Therapy

Advances in radiation therapy (TrueBeam IMRT) have allowed radiation therapy to be delivered to the prostate with more precision and more safety than ever before. Being able to deliver radiation with higher accuracy allows doctors to treat the cancer with higher doses of radiation, thereby improving cancer outcomes while minimizing any side-effects. The TrueBeam IMRT is the most advanced IMRT system in the world and there are only a few in the country. At the Prostate Cancer Institute of LA, we are proud to be able to offer this treatment modality to our patients.


Radiation therapy can also be delivered by placing radiation “seeds” into the prostate. This approach is optimized by being able to fuse the MRI and ultrasound information together (MR fusion brachytherapy) at the time of therapy. Brachytherapy offers the advantage of treating a patient in one setting (IMRT requires several weeks of treatments).

High-Intensity focused Ultrasound (HIFU)

High intensity focused ultrasound (HIFU) is a new and exciting modality that offers cancer cure in an outpatient setting. By being able to focus intensified ultrasound waves on a tumor, a tumor can be destroyed with great precision. This precision allows patients to undergo treatment of their cancer while optimizing preservation of their normal functions.

Contact Our Expert Urologists Today

At Comprehensive Urology of LA, we perform the necessary tests involved with grading and staging cancer. Though prostate cancer can be slow growing, it’s very important to be tested as early as possible. As with all cancers, early identification can be extremely useful when treating the disease. Please contact our center to schedule a consultation today.

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