The 4 Stages Of Prostate Cancer (And What Happens At The End)

Prostate cancer begins in the prostate, a small gland located just below the bladder, present only in people assigned male at birth (AMAB). This gland is in charge of producing seminal fluid, and it grows slowly with age. However, when prostate cancer starts to develop, its cells start growing uncontrollably, meaning that it increases in size more rapidly than usual. 

The rate at which the prostate grows depends on the type of prostate cancer. According to the American Cancer Society (ACS), prostate cancer is the most common non-skin cancer among people AMAB in the U.S., with an estimated 313,780 new cases expected in 2025 alone. When it comes to the chances of developing this cancer, several factors come into play, with old age being the strongest one. Other risk factors for prostate cancer are ethnicity, family history, exposure to certain chemicals, and lifestyle factors.

Many people diagnosed with prostate cancer can live long and healthy lives. In fact, this cancer has a 100% survival rate when detected early. However, the course of the disease can vary widely depending on when it’s detected and how aggressively it behaves. Thus, understanding the stages of prostate cancer is crucial for making informed decisions about treatment, lifestyle changes, and long-term planning. Doctors classify prostate cancer into four main stages based on how far the cancer has spread within or beyond the prostate. Each stage has its own set of characteristics, treatment options, and potential outcomes.

Unlike many other types of cancers, which have specific telltale signs or symptoms that help you get the help you need promptly, prostate cancer is known to have very few warning signs, if symptoms even appear. Therefore, early detection of prostate cancer often begins with screening, a process that helps identify potential cancer before it’s too late. The two most common screening tools are the prostate-specific antigen (PSA) blood test and the digital rectal exam (DRE). The PSA test measures the antigen levels in your blood, with higher levels increasing the chances of a positive diagnosis. In contrast, the DRE is a manual exam performed through the rectum to detect any lumps or abnormalities.

However, the ACS warns that neither is 100% effective in finding the cancer. This is because numerous factors can affect your PSA levels, and a DRE can only warn against potential cancer if the tumor is located in a reachable area of the gland. This means that abnormal results tend to lead to official diagnostic tests, which include imaging tests, such as ultrasounds and MRIs, and, most importantly, a prostate biopsy, where a sample of prostate tissue is removed and analyzed under a microscope to confirm whether cancer is present. While PSA tests and biopsies are key to detecting prostate cancer, they are also critical to the staging process that follows a confirmed diagnosis, as per the TNM staging system, which is prostate cancer’s primary form of staging (via the ACS).

Once cancer is diagnosed, its stage refers to how advanced the cancer is, meaning that it tells doctors whether it is still in the main organ (in this case, the prostate) or if it has spread to nearby tissues or distant organs. The most commonly used system is the TNM staging system developed by the American Joint Committee on Cancer (AJCC). This 3-stage classification method analyzes tumor, nodes, and metastasis, as well as your previously determined PSA levels and the Gleason score (via the NLM). Once your doctor determines your TNM score, prostate cancer is grouped into four overall stages that help healthcare providers recommend the most appropriate treatment and give you a clearer picture of what to expect (via the ACS). The lower the number, the less aggressive the cancer.

T refers to the size and extent of the tumor within the prostate or surrounding tissues. This component can also be staged from T1 to T4 as follows: T1 tumors are so small they can’t be felt during a DRE and are only confirmed through biopsy, while T2 tumors can be felt through a DRE, and T3 or T4 tumors have grown beyond the prostate and may involve nearby structures. N tells you whether the cancer has spread to nearby lymph nodes. It is divided into N0 (no lymph node involvement), N1 (cancer cells have been found in regional nodes), and NX (node involvement can’t be determined). Lastly, M describes whether the cancer has spread (metastasized) to distant parts of the body. M0 means no distant spread, M1 confirms the cancer has moved beyond the pelvic region, and MX means metastasis can’t be determined (via the Prostate Cancer Foundation).

Since staging cancer is key to determining its treatment path, one crucial factor is understanding how aggressive the cancer is, and that’s where the Gleason grading system comes in. This means that, besides analyzing a tumor’s size and spread, this specific element of the TNM staging system is meant to predict how quickly the cancer is likely to grow and spread, and it relies on biopsy results to do so. The Gleason grading system is composed of a Gleason grade and a Gleason score, the latter of which is the result of the two most common grades present in the tumor.

When a pathologist examines prostate tissue from a biopsy, they assign two grades on a scale of 1 to 5, reflecting how much the cancer cells differ from normal prostate cells. These two grades come from the two most predominant areas in the tumor sample. A grade of 1 looks nearly normal, while a grade of 5 shows highly abnormal, disorganized cells. Once the two most common patterns in the sample are determined, their sum forms the Gleason score, which ranges from 6 to 10. Per the ACS, just as with the TNM staging system, a higher score means a more aggressive cancer that’s more likely to grow quickly and spread. Lastly, doctors have developed another scoring system, Grade Groups, to avoid potential misunderstandings. These are based on the cancer’s Gleason score and again range from 1 to 5, from least to most likely to grow and metastasize.

Stage 1 prostate cancer is considered the earliest and least aggressive form of the disease. At this stage, the cancer is small, contained entirely within the prostate, and often not causing any noticeable symptoms. In fact, stage 1 prostate cancer is almost always discovered by chance during routine PSA testing or through biopsy when examining other prostatic problems, such as benign prostatic hyperplasia (BPH), because it can seldom be felt by DRE (per the National Cancer Institute (NCI)). When a DRE catches an anomaly, the cancer tends only to occupy less than one side of the prostate gland. Per the TNM system, this would categorize the cancer as typically T1 or T2, N0 (no lymph node involvement), and M0 (no metastasis). Plus, its PSA levels are usually lower than 10, and the Gleason score is no more than 6, indicating that the cancer cells are similar in appearance to normal cells and are growing slowly.

Given this type of prostate cancer’s expected slow progress, treatment options typically begin with active surveillance, meaning no treatment is given unless the cancer starts to grow. Still, this doesn’t mean the cancer is not closely monitored. On the contrary, regular tests ranging from blood tests to repeat biopsies are routinely scheduled. The goal is to avoid unnecessary treatments and side effects while still catching any signs of progression early. However, once the cancer progresses, treatment options may include hormone therapy, surgery, or radiation therapy to remove or destroy the cancer before it spreads.

According to the NCI, stage 2 prostate cancer is still confined to the prostate gland. However, it may be larger, involve more of the prostate tissue, or exhibit more abnormal-looking cells under the microscope, meaning it is more likely to spread. Stage 2 prostate cancer is divided into subcategories 2A, 2B, and 2C based on the size of the tumor, PSA levels, and Grade Group. For example, stage 2A is characterized by a small tumor, PSA levels between 10 and 20, and the Grade Group is 1. In contrast, stage 2B usually has a medium-sized tumor present on one or both sides of the prostate, a PSA level under 20, and its Grade Group is 2, whereas stage 2C may involve a tumor comprising both sides of the prostate, still a PSA level of less than 20, but its Grade Group is 3 or 4, suggesting a more aggressive cancer. Yet, since it is still a localized cancer, it would still receive an N0 and M0 within the TNM system.

Nevertheless, despite its localized nature, managing stage 2 prostate cancer with active surveillance alone might only be part of your initial treatment plan, as treatment might require additional therapies. Common treatment options for this stage include radical prostatectomy (a.k.a surgical removal of the prostate), radiation therapy, which might vary between external beam radiation therapy (EBRT) or brachytherapy (a.k.a internal radiation), depending on your doctor’s assessment, or hormone therapy to shrink or slow the growth of cancer cells. However, this isn’t really a cure.

Stage 3 prostate cancer marks the point where the disease begins to extend beyond the prostate gland itself, indicating a more aggressive form of cancer that requires active treatment. In the TNM system, this stage might include any T tumors that have grown through the prostate. Yet, it is still largely classified as N0 and M0, as it hasn’t yet spread to lymph nodes or distant organs. Per the NCI, stage 3 prostate cancer is again subdivided into 3A, 3B, and 3C, depending on whether it has spread to nearby tissues and its overall Grade Group. For example, stage 3A is still limited to the prostate, but it already affects both sides. Its PSA is over 20, and the Grade Group might range between 1 and 4. In contrast, stages 3B and 3C typically refer to cancers already spreading to the seminal vesicles and other organs within the pelvic cavity, like the rectum or bladder. However, the main difference between the two is that while stage 3B’s Grade Group is still between 1 and 4, stage 3C’s is now 5, which is the likeliest to result in a faster spread.

Since stage 3 cancer is no longer restricted to the prostate, treatment options typically consist of a combination of therapies. These usually include EBRT, often combined with hormone therapy and vice versa, and radical prostatectomy followed by EBRT. However, you might be surprised to know that, despite the growing aggressiveness of this stage, active surveillance is still on the table (via the NCI).

Stage 4 prostate cancer is the final and most advanced stage, indicating that the cancer has spread beyond the prostate to nearby lymph nodes or other nearby and distant organs such as the bladder, liver, bones, or lungs. For that reason, it is also known as metastatic prostate cancer. Per the Canadian Cancer Society, this stage is divided into 4A and 4B, with the main difference being that the former indicates a nearby spread that might have affected the lymph nodes, while the latter shows a distant spread. This means that, per the TNM system, stage 4A prostate cancer is classified with any T, N1, and M0. In contrast, stage 4B is classified with any T, any N, and M1.

Unlike any of the previous stages, stage 4 prostate cancer is the most likely to bring noticeable symptoms, such as fatigue, weight loss, and problems that reflect the affected organs where the cancer might have spread. For example, if it reaches the liver, lungs, or bones, it might lead to jaundice, shortness of breath, and increased risk of fractures, respectively. Also, unlike the previous stages, there is no cure for stage 4 prostate cancer. Instead, treatment shifts to managing it as a chronic condition, improving quality of life, and extending survival. Standard treatment options include hormone therapy, targeted therapy for specific genetic markers, chemotherapy, radiation, immunotherapy, and surgery.

In the final phase of prostate cancer, sometimes referred to as end-stage or terminal prostate cancer, the disease has progressed significantly, and treatment is no longer controlling its spread or symptoms effectively. This stage often happens after years of living with stage 4 or metastatic prostate cancer and is characterized by increasing physical symptoms and a shift in treatment goals. Common signs that prostate cancer has entered its final stage include persistent pain, extreme fatigue, loss of appetite, shortness of breath, confusion, restlessness, changes in bowel movements and urination patterns, skin changes, and death rattle. According to a 2018 study in BMC Palliative Care, these symptoms can severely affect the quality of life of people with stage 4 prostate cancer. Thus, it suggests a focus shift from curative treatment to palliative care, an approach aimed at relieving pain and other symptoms, improving comfort, and maintaining the highest possible quality of life.

Palliative care can be provided alongside ongoing treatments or on its own. However, an article published in Translational Andrology and Urology recommends starting it alongside traditional treatment options, as it also helps improve treatment-associated side effects. Nevertheless, it shares that palliative care is often underutilized due to its association with a failed or unfavorable cancer prognosis. Lastly, when life expectancy is thought to be six months or less, many start looking towards hospice care, a service that provides support by focusing entirely on comfort and dignity in the final months of life rather than trying to cure cancer.

For many people, a diagnosis of prostate cancer does not mean a death sentence. In fact, early-stage diagnosis allows for a wide range of safe and effective management strategies that improve the outcome. For instance, the prognosis for stage 1 and 2 prostate cancer is excellent, with a 5-year survival rate of nearly 100%, meaning that many live for decades without the cancer ever becoming a serious health threat. Similarly, the outlook for stage 3 prostate cancer is still very favorable, with a 5-year survival rate of roughly 95%. Lastly, although stage 4 cancer is not curable in most cases, about 50% of people with this diagnosis will survive the cancer within the first five years with the right treatment and support (per Cancer Research UK).

This means that millions of people are currently living with or beyond prostate cancer, leading full and active lives. However, the key is to stay on top of your follow-up care, which might involve regular PSA monitoring, DREs, and maintaining healthy habits, such as leading an active lifestyle, following a healthy diet, and quitting smoking. In addition, taking care of your emotional health is also an important part of life beyond prostate cancer, as people might become more anxious or stressed about the possibility of the cancer returning.

Getting a stage 4 prostate cancer diagnosis can result in a wide range of feelings, especially when it’s identified late or after previous treatments stop working. While about half of the people with advanced prostate cancer live for several years thanks to modern therapies, others face a more rapid disease progression, resulting in a mix of emotions that vary from grief, loneliness, depression, and anger to relief or acceptance. No matter how you might feel, know that your emotions are valid and normal and that coping with terminal cancer involves navigating both the physical realities of the illness and the emotional challenges that come with it.

Additionally, it might be wise to start getting your affairs in order and plan for your final wishes when time is running out. These types of conversations, while challenging, allow loved ones to honor your preferences and values. They might include details about your end-of-life care, like how you’d like your symptoms to be managed or where you’d like to pass. Yet, they can also cover legal and financial matters, such as your will or insurance policies. Though the end-of-life path is never easy, with compassionate care and support, the final chapter can be approached with comfort, dignity, and love.