Prostate Cancer Staging: TNM, PSA, Grade Group and Risk Groups
Prostate cancer stage combines four things: TNM, your PSA blood level, and your Grade Group (a simpler version of the Gleason score). It runs from stage I to stage IVB under the AJCC 8th edition, which is still current in 2026. When the cancer has not spread, doctors often rely more on a risk group, from very low to very high, to choose treatment.
Prostate cancer is different from most cancers because stage is not based on anatomy alone. A high PSA or a high Grade Group can raise the stage even when the tumor is still inside the prostate. New to staging? See our guide to cancer stages and the TNM staging reference. Our prostate cancer guide covers the disease itself.
T: the main tumor
Clinical T (cT) comes from a digital rectal exam, where the doctor feels the prostate with a gloved finger. Imaging can add detail. Pathological T (pT) comes from the prostate after surgery.
| T | What it means |
|---|---|
| T1a | Cannot be felt. Found by chance in 5% or less of tissue removed for another reason. |
| T1b | Cannot be felt. Found by chance in more than 5% of tissue removed. |
| T1c | Cannot be felt. Found by needle biopsy, on one or both sides. |
| T2a | Can be felt. In half of one side or less. |
| T2b | Can be felt. In more than half of one side, but not both sides. |
| T2c | Can be felt. On both sides. |
| pT2 | After surgery: confined to the prostate. |
| T3a | Has grown outside the prostate. After surgery, this also includes microscopic spread into the bladder neck. |
| T3b | Has grown into the seminal vesicles, the small glands next to the prostate. |
| T4 | Is fixed in place, or has grown into nearby structures such as the rectum, bladder, external sphincter, pelvic muscles or pelvic wall. |
N and M: lymph nodes and distant spread
| Category | What it means |
|---|---|
| NX | Regional nodes were not assessed. |
| N0 | No cancer in regional lymph nodes. |
| N1 | Cancer in regional lymph nodes. |
| M0 | No distant spread. |
| M1a | Spread to lymph nodes outside the pelvis region. |
| M1b | Spread to bone. |
| M1c | Spread to other sites, with or without bone. |
PSA and Grade Group
PSA (prostate-specific antigen) is a protein made by the prostate and measured in a blood test, in nanograms per milliliter (ng/mL). Staging uses the level at diagnosis.
The Gleason score describes how abnormal the cancer cells look. A pathologist gives two numbers for the two main patterns in the tumor and adds them. Grade Group turns this into a simple scale from 1 to 5. A higher Grade Group means the cancer is more likely to grow and spread quickly.
| Grade Group | Gleason score | Gleason patterns |
|---|---|---|
| 1 | 6 or less | 3+3 or lower |
| 2 | 7 | 3+4 |
| 3 | 7 | 4+3 |
| 4 | 8 | 4+4, 3+5 or 5+3 |
| 5 | 9 or 10 | 4+5, 5+4 or 5+5 |
Notice that 3+4 and 4+3 both add up to 7 but are different Grade Groups. The first number is the most common pattern, so 4+3 has more of the higher-grade pattern.
Prostate cancer stage chart
| Stage | T | N | M | PSA (ng/mL) | Grade Group |
|---|---|---|---|---|---|
| I | cT1a to c, cT2a, or pT2 | N0 | M0 | Under 10 | 1 |
| IIA | cT1a to c, cT2a, or pT2 | N0 | M0 | 10 to under 20 | 1 |
| IIA | cT2b or cT2c | N0 | M0 | Under 20 | 1 |
| IIB | T1 or T2 | N0 | M0 | Under 20 | 2 |
| IIC | T1 or T2 | N0 | M0 | Under 20 | 3 or 4 |
| IIIA | T1 or T2 | N0 | M0 | 20 or higher | 1 to 4 |
| IIIB | T3 or T4 | N0 | M0 | Any | 1 to 4 |
| IIIC | Any T | N0 | M0 | Any | 5 |
| IVA | Any T | N1 | M0 | Any | Any |
| IVB | Any T | Any N | M1 | Any | Any |
Stage IV does not always mean distant spread here. Stage IVA means cancer in nearby lymph nodes with no distant spread. Only stage IVB is metastatic. If you are told "stage 4," ask which one.
Risk groups: D'Amico and NCCN
Most prostate cancers are found before they have spread. Stage alone does not separate these cases well, so doctors also use risk groups. These estimate how likely the cancer is to grow or come back, and they steer treatment choices. They use the same pieces: T, PSA and Grade Group.
The original D'Amico groups
Published in 1998, this system has three groups. It was built to estimate the chance of PSA rising after treatment.
| Group | Criteria |
|---|---|
| Low | All of: T1c or T2a, PSA 10 or lower, Gleason 6 or lower |
| Intermediate | Not low or high, with T2b, PSA over 10 up to 20, or Gleason 7 |
| High | Any of: T2c, PSA over 20, Gleason 8 or higher |
NCCN groups
The National Comprehensive Cancer Network (NCCN) groups are more detailed. This summary comes from the American Cancer Society's description of NCCN Version 2.2023. NCCN updates its guideline often, so ask your doctor which version was used.
| Group | Criteria | Options often discussed |
|---|---|---|
| Very low | cT1c, Grade Group 1, PSA under 10, plus limited cancer on biopsy | Active surveillance |
| Low | cT1 to cT2a, Grade Group 1, PSA under 10 | Active surveillance. Surgery or radiation by preference |
| Intermediate (favorable) | cT2b or cT2c, Grade Group 2 or 3, or PSA 10 to 20, with other factors deciding favorable or unfavorable | Active surveillance, surgery or radiation |
| Intermediate (unfavorable) | As above, with less favorable factors | Surgery with node removal, or radiation with hormone therapy, or radiation with brachytherapy |
| High | One of: cT3a, Grade Group 4 or 5, PSA over 20 | Radiation with hormone therapy, or surgery with node removal |
| Very high | At least one of: cT3b or cT4, primary Gleason pattern 5, more than 4 biopsy cores of Grade Group 4 or 5, or 2 to 3 high-risk features | Same as high risk. Abiraterone is often added to hormone therapy with radiation |
Active surveillance means closely watching the cancer with PSA tests, exams and repeat biopsies, and treating only if it shows signs of growing. It is not the same as doing nothing.
Tests used to see if the cancer has spread
Many men with cancer that seems confined to the prostate do not need these scans. Your team decides based on your risk group.
- Bone scan: looks for cancer in bones, where prostate cancer often spreads first.
- CT scan: checks nearby lymph nodes.
- MRI: shows whether cancer has reached the seminal vesicles or nearby structures.
- PSMA PET scan: used when a bone scan is unclear or PSA rises after treatment with no known site.
Stage IV treatment
Stage IVA options can include radiation with hormone therapy, hormone therapy alone, or surgery for some men. Stage IVB usually cannot be cured, so treatment aims to control the cancer and protect quality of life. Options include hormone therapy, often with abiraterone, apalutamide or enzalutamide, and sometimes docetaxel chemotherapy. Some gene changes open up targeted combinations. Bone pain may be managed with radiation and bone drugs. See bone health and what stage 4 cancer means.
Prostate cancer survival by stage
US survival figures use SEER stages, not stages I to IV. Regional in SEER includes cancer in nearby lymph nodes, so it includes some stage IVA cancers.
| SEER stage | Share of cases | 5-year relative survival (2016 to 2022) |
|---|---|---|
| Localized | 69% | 100.0% |
| Regional | 14% | 100.0% |
| Distant | 9% | 40.1% |
| All stages | 100% | 98.2% |
Shares do not add to 100% because unstaged cases are not shown. Relative survival compares men with prostate cancer to similar men without it. A figure of 100% means they lived as long as those men over 5 years, not that nobody died or that every cancer was cured. Our guide to prognosis explains more.
Call your care team now if you cannot pass urine, have new back pain with leg weakness or numbness, or lose control of your bladder or bowels. New severe back pain with these signs can mean pressure on the spinal cord, which is an emergency. Also call for a fever of 100.4°F (38°C) or higher during chemotherapy. See when to call your doctor.
Frequently asked questions
Why is my prostate cancer stage 3 if it is still inside the prostate?
Prostate cancer stage uses PSA and Grade Group as well as anatomy. A PSA of 20 ng/mL or higher makes T1 or T2 cancer stage IIIA, and Grade Group 5 makes any cancer without nodes or spread stage IIIC, even if it is confined to the prostate.
What is the difference between Gleason score and Grade Group?
They come from the same microscope findings. Grade Group is a simpler scale from 1 to 5. Grade Group 1 equals Gleason 6 or less, and Grade Group 5 equals Gleason 9 or 10. Grade Group also separates 3+4 from 4+3, which both add up to Gleason 7.
Does a high PSA mean the cancer has spread?
Not by itself. PSA of 20 ng/mL or higher raises the stage and the risk group, but only scans or biopsies can show spread. Your doctor uses PSA along with Grade Group and the exam to decide which scans you need.
Is stage 4 prostate cancer always metastatic?
No. Stage IVA means cancer in nearby lymph nodes without distant spread. Stage IVB means distant spread, such as to bone. Treatment and outlook differ, so ask which one you have.
Do I need treatment right away for low-risk prostate cancer?
Often not. Most men with very low or low risk cancer are offered active surveillance, which means regular monitoring and treatment only if the cancer shows signs of growth. Surgery or radiation are alternatives if you prefer them.
What is the difference between stage and risk group?
Stage describes how far the cancer has reached, using TNM, PSA and Grade Group. A risk group estimates how the cancer that has not spread is likely to behave, and helps choose treatment. You may see both on your records.
Sources
- FACS: AJCC Current Staging System table (2026)
- National Cancer Institute: Prostate Cancer Treatment (PDQ), health professional version
- American Cancer Society: Prostate Cancer Stages
- American Cancer Society: Risk Groups and Lab Tests for Localized Prostate Cancer
- American Cancer Society: How Prostate Cancer Is Diagnosed
- American Cancer Society: Initial Treatment of Prostate Cancer, by Stage and Risk Group
- American Cancer Society: Survival Rates for Prostate Cancer
- SEER: Cancer Stat Facts, Prostate Cancer
- D'Amico AV et al. JAMA 1998: Biochemical Outcome After Radical Prostatectomy, External Beam Radiation Therapy, or Interstitial Radiation Therapy
This page is general information, not medical advice. Your care team knows your situation and should guide your decisions.