Risk Category

Your risk category is determined following all the diagnostic tests, before any treatment is undertaken. The NICE Guidelines for Prostate Cancer (2019) give three categories of risk:

Low risk, Intermediate risk and High risk

Depending on a combination of PSA, DRE, Gleason score, ISUP score and T stage, you will fit into a ‘risk’ category. Knowing this risk category will help decide the most appropriate treatment for you (see chart).

There can also be a subset of ‘very high risk’ in which the tumour has extended into the seminal vesicles (T3b) or the rectum or bladder (T4), or there are multiple biopsy samples with high grade cancer.

Currently, there are ongoing efforts to develop tests that can aid physicians more accurately to distinguish cancers that will become fatal from those that will sit in the prostate without spreading. Treatment options for each risk group are very different and you should ask your doctor which risk group you belong to, so you can better understand the options available to you.

Risk stratification for people with localised prostate cancer

  Level of risk PSA   Gleason
score
  Clinical
stage

  Low

<10 ng/ml

and

<6

and

T1 to T2a

  Intermediate

10–20 ng/ml

or

7

or

T2b

  High*

>20 ng/ml

or

8 to 10

or

T2c

NICE guideline, May 2019

* High-risk localised prostate cancer is also included in the definition of locally advanced prostate cancer

The categories describing prostate cancer

Localised (or early stage) cancer – where the cancer has been found to be enclosed within the prostate.

TNM staging – either T1 or T2, NO, MO

Locally advanced cancer – where the cancer has been found to have broken through the outer capsule and begun to spread outside the prostate, e.g. into the seminal vesicles, the lymph nodes near the prostate, the rectum (back passage) or the bladder.

TNM staging – either T3 or T4, N1, MO

Note: high-risk localised prostate cancer, PSA higher than 20ng/ml, or Gleason Score between 8 and 10, may also be included in the definition of locally advanced prostate cancer even though the cancer is still enclosed within the prostate.

Advanced cancer (sometimes known as metastatic cancer) will have spread from the prostate to other more distant parts of the body.

See Hormone Treatment section, which includes a diagram of the lymphatic system and a diagram showing possible areas of prostate cancer spread. 

TNM staging - T4, any N, any M