What Are Prostate Cancer Risk Groups?

Once your prostate cancer has been diagnosed, or as it continues to progress, you may be categorized into a risk group. Risk groups, as described by the National Comprehensive Cancer Network (NCCN), are categories based on the risk of a man’s cancer spreading or becoming more advanced. These groups help determine a man’s overall prognosis, and indicate what treatment options may be the most beneficial. Your cancer may not always behave exactly as expected for the group you’re assigned to, and your treatment options may be different as well. Personal wishes and previous medical history may be influence what your next steps are more than the stage or grade of your cancer. There are seven main risk groups outlined by the NCCN, and each group has their own set of recommended primary treatment options.1

Very low risk

Men with very low risk of their cancer advancing typically have all 5 of the following characteristics:

  • Cancer stage T1c, N0, M0 (based on the TNM system)
  • PSA level less than 10 ng/mL
  • PSA density less than 0.15 ng/mL/g
  • Gleason score less than or equal to 6
  • Fewer than three biopsy cores containing cancer (and these cells making up half or less of all cells in the core)

After a man is determined to be at very low risk for his cancer advancing, his treatment options will be based on his life expectancy. If his life expectancy is less than 10 years, or is 10-20 years, the primary treatment option may be observation or active surveillance with regularly scheduled exams including further PSA tests, prostate biopsies, or digital rectal exams. If a man with very low risk prostate cancer is expected to live longer than 20 years, his treatment options may include active surveillance, radiation therapy, or surgical treatment.

Low risk

Men with low risk of their cancer advancing typically have all 3 of the following characteristics:

Similar to men at very low risk, life expectancy will be used to determine treatment options for men with men with low risk. If his life expectancy is less than 10 years, observation is typically the treatment decision made. If a man is expected to live longer than 10 years, he may undergo active surveillance, radiation therapy, or surgical treatment.

Intermediate risk

Men with intermediate risk of their cancer advancing typically have one of the 3 following characteristics:

  • Cancer stage T2b or T2c, N0, M0
  • PSA level between 10 and 20 ng/mL
  • Gleason score of 7

If you possess more than one of these characteristics, your cancer may be treated as high risk. For men considered to be at intermediate risk, treatment options may include observation or radiation therapy if they have a life expectancy of less than 10 years. If they have a life expectancy of more than 10 years, surgery and radiation therapy may be considered.

High risk

Men with high risk of their cancer advancing typically have one of the 3 following characteristics:

  • Cancer stage T3a, N0, M0
  • PSA level greater than 20 ng/mL
  • Gleason score between 8 and 10

If you possess more than one of these characteristics, your cancer may be treated as very high risk. Regardless of their life expectancy, the primary treatment options for men with high risk prostate cancer include the following:

  • External beam radiation therapy (EBRT) and androgen deprivation therapy (hormone therapy) for two to three years with or without chemotherapy
  • EBRT and brachytherapy (internal radiation therapy) with or without androgen deprivation therapy for two to three years
  • Surgery (radical prostatectomy) and pelvic lymph node dissection

Very high risk

Men with very high risk of their cancer advancing typically have one of the 3 following characteristics:

  • Cancer stage T3b or T4 and N0, M0
  • Greater than four biopsy samples with Gleason scores between 8 and 10
  • Primary Gleason grade of 5

The treatment options for men with very high risk prostate cancer are the same for high risk prostate cancer. The only difference is that androgen deprivation therapy can be used on its own for symptom management when the cancer is thought to be incurable by the other treatment options.

Regional cancer

Men in this group have cancer that has spread to the nearby lymph nodes. They can be in any T category, and have N1 and M0. Primary treatment options for these individuals include:

  • EBRT and androgen deprivation therapy for two to three years
  • Androgen deprivation therapy
  • Orchiectomy (the surgical removal of the testicles as a form of hormone management)

Metastatic cancer

When cancer spreads to distant parts of the body it is said to have metastasized (M1). This is the most advanced category of cancer. Primary treatment options for these individuals include:

  • Orchiectomy
  • Androgen deprivation therapy
  • Androgen deprivation therapy and chemotherapy together (with or without prednisone)

Your doctor will utilize guidelines like these, as well as the results from any tests you may have had and combine this information together with your past medical history and personal wishes to determine the appropriate treatment options for you. If you feel uncomfortable or unsure about the treatment options provided to you, you can seek a second opinion at any time. Your doctor will also let you know the approximate prognosis of your case, and the chances that your cancer could be cured.

Written by: Casey Hribar | Last reviewed: October 2017
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