Localized prostate cancer

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Localized prostate cancer

Prostate cancer: How do doctors estimate how it will progress?

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Whether and how prostate cancer continues to grow will vary from person to person: Some tumors are small and grow either slowly or not at all. Others are large and grow rapidly. Various examinations can be used to predict which group the cancer is in.

Prostate cancer can be treated in different ways. The cancer can be surgically removed or treated with radiotherapy. It is also possible to wait and check regularly to see if the cancer is growing. When choosing a treatment, it's important to know how the cancer will probably progress. The treatment options will mainly depend on two factors:

  • Tumor size (stage)
  • The likelihood that it will grow (risk of progression)

Doctors can use various tests determine the stage of the tumor and the risk of progression, including:

  • Feeling the prostate (palpation). Palpation is not very accurate, though.
  • Imaging techniques like ultrasound and (MRI)
  • A blood test to determine the prostate-specific antigen level (PSA level)
  • Tissue sample ("punch" biopsy)

If the cancer is at an advanced stage, further imaging techniques such as (CT) or positron emission tomography (PET) can be used in order to see whether it has led to tumors (metastases) in other parts of the body.

How is the tumor stage determined?

The tumor stage describes how big the tumor is and whether it has already spread. Doctors use a specific classification called TNM:

  • T describes how much the tumor has spread.
  • N shows whether the lymph nodes are affected.
  • M indicates whether metastases have formed.

The following table shows the tumor stages.

Table: Information used in the TNM staging system for prostate cancer, and what the categories mean
Factor Category Subcategory
Original tumor (primary tumor) T1:
The tumor is so small that it can't be detected by using palpation (feeling with a finger) or ultrasound exams.
 T1a:
The tumor is found by chance, and less than 5% of the tissue contains cancer cells.
T1b:
The tumor is found by chance, and more than 5% of the tissue contains cancer cells.
T1c:
After high PSA levels were measured, cancer cells were found in tissue samples (a biopsy).
T2:
The tumor can be felt with a finger or seen in an ultrasound, but has not yet spread to other parts of the body.
 T2a:
The tumor is in less than half of one side (left or right) of the prostate.
T2b:
The tumor is in more than half of one side (left or right) of the prostate.
T2c:
The tumor is in both sides of the prostate.
T3:
The tumor has spread outside the prostate into the connective tissue around the prostate or the seminal vesicles. 		 
T4:
The tumor has spread further, to nearby organs such as the bladder or bowel. 		 
Lymph nodes N0:
There are no tumors in nearby lymph nodes.
N1:
Nearby lymph nodes are affected. 		 
Metastases M0:
No metastatic tumors were found.
M1:
Metastatic tumors were found. 		 

The following information is about localized prostate cancer. In other words, The cancer is limited to the prostate (T1 and T2 category tumors), has not affected any lymph nodes (N0) and has not metastasized (M0). So, for instance, T2a N0 M0 would be one possible TNM classification for a particular case of localized prostate cancer.

How is the risk of progression determined?

Doctors categorize localized tumors into different risk groups based on how likely they are to progress. To do this, they need the following information:

  • The exact tumor stage (TNM)
  • The PSA levels
  • The Gleason score

The Gleason score is determined based on what the tissue samples look like under the microscope. It describes how much the prostate cells have changed. Tumors with a lower score grow more slowly than tumors with a higher score. The Gleason score for prostate cancer is between 6 and 10 when it's determined using tissue samples from a biopsy.

The number representing the most common cell pattern and the number representing the most aggressive cell pattern are added to get the total Gleason score. For example, if the most common pattern is 3 and the most aggressive pattern is 4, the Gleason score is 7.

The cancer is assigned to one risk group based on the tumor stage, the PSA level and the Gleason score. There are typically three categories:

  • Low risk
  • Intermediate risk
  • High risk

The following table shows the criteria for the three risk groups. It also shows which treatment options are generally considered for these groups.

Table: Risk groups for localized prostate cancer
Risk Criteria Treatment options
Low risk These three criteria all apply:

  • Tumor stage: up to T2a
  • PSA level: up to 10 nanograms per milliliter (ng/ml)
  • Gleason score: 6
Intermediate risk At least one of these criteria applies:

  • Tumor stage: T2b
  • PSA level: between 10 and 20 ng/ml
  • Gleason score: 7
  • External radiotherapy
  • Combination of internal and external radiotherapy
  • Surgery to remove the prostate

    Active monitoring is also possible if the tumor has certain characteristics.
High risk At least one of these criteria applies:

  • Tumor stage: T2c
  • PSA level: more than 20 ng/ml
  • Gleason score: 8 or more
  • External radiotherapy
  • Combination of internal and external radiotherapy
  • Surgery to remove the prostate

Deutsche Gesellschaft für Urologie (DGU). S3-Leitlinie Prostatakarzinom (Leitlinienprogramm Onkologie). AWMF register no.: 043-022OL. 2025.

Donovan JL, Hamdy FC, Lane JA et al. Patient-reported outcomes after monitoring, surgery, or radiotherapy for prostate cancer. N Engl J Med 2016; 375(15): 1425-1437.

Hamdy FC, Donovan JL, Lane JA et al. 10-year outcomes after monitoring, surgery, or radiotherapy for localized prostate cancer. N Engl J Med 2016; 375(15): 1415-1424.

Robert Koch-Institut (RKI), Zentrum für Krebsregisterdaten (ZfKD). Krebs in Deutschland für 2019/2020. Berlin: RKI; 2023.

IQWiG health information is written with the aim of helping people understand the advantages and disadvantages of the main treatment options and health care services.

Because IQWiG is a German institute, some of the information provided here is specific to the German health care system. The suitability of any of the described options in an individual case can be determined by talking to a doctor. informedhealth.org can provide support for talks with doctors and other medical professionals, but cannot replace them. We do not offer individual consultations.

Our information is based on the results of good-quality studies. It is written by a team of health care professionals, scientists and editors, and reviewed by external experts. You can find a detailed description of how our health information is produced and updated in our methods.

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Prostate cancer: How do doctors estimate how it will progress?

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Updated on February 25, 2026

Next planned update: 2029

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Institute for Quality and Efficiency in Health Care (IQWiG, Germany)

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