The 15 stages of Prostate Cancer

A very interesting article by:

Mark Scholz, MD | Reviewed by Richard N. Fogoros, MD

Updated June 01, 2018

There are many barriers to achieving optimal care for prostate cancer. First of all, as we will see by the end of this article, prostate cancer is intricate, which means determining the most appropriate therapy can be complicated. Second, the endless amount of disorganized and out-of-date information on the Internet is daunting and unmanageable. Doctors, let alone patients become overwhelmed.

 Third, face-time between patients and doctors is continually shrinking due to the expansion of big business and government into medical care. On top of these problems, consider how almost no doctors specialize in treatment selection. They merely specialize in either surgery or radiation, so the decision-making process gets left to the patient.

Should Patients Be in Charge of Choosing a Treatment Plan?

Doctors who care for prostate cancer patients are sensitive to the limitations listed above. And they realize there are other problems as well. The first is that doctors have a major conflict of interest. They are paid to carry out only one type of therapy, surgery or radiation. As a result, they are reticent to give forceful treatment recommendations. How many times have patients heard from their doctor, “You need to be the one who decides"?

Second, predicting the seriousness of a patient’s cancer is impaired by prostate cancer’s extremely slow-growing nature.

It takes a decade for the impact of a treatment decision to be realized. Predictions are further impaired by the elderly profile of prostate cancer patients. Mortality from old age is often a bigger risk than the cancer itself. Lastly, in the context of this mild, slow-growing cancer, the impact of treatment on quality-of-life—things like impotence or incontinence—may be greater than the impact on survival.

Who is better positioned to balance quality-of-life priorities with survival than the patient?

Knowing Your Stage

Participating in the treatment selection process is therefore unavoidable for prostate cancer patients. Selection of treatment revolves around the cancer’s stage, the patient’s age, and his quality-of-life objectives. As a result, knowing the cancer’s stage is crucial:

• It reduces the number of therapeutic options and avoids the need to sift through vast amounts of unessential information.
• It improves patient-doctor communication. Doctors can skip over basic explanations about stage and jump right to a comparative discussion about the most commonly used treatments for that individual’s specific stage.
• It is the best way to obtain an accurate perspective of the cancer’s risk and the urgency (or the lack thereof) for more aggressive treatment (see below).

The Five Stages of Blue

There are five major stages of prostate cancer—Sky, Teal, Azure, Indigo, Royal—each containing three subtypes termed Low, Basic and High, for a total of 15 levels. The first three stages, Sky, Teal, and Azure are very similar to the standard risk categories of Low, Intermediate, and High-Risk diseases which were developed by Anthony D’Amico of Harvard Medical School.

Indigo and Royal represent relapsed and advanced prostate cancer, respectively. There are a number of other staging systems, but they all have shortcomings. Only the Stages of Blue represent the full spectrum of prostate cancer.

The Risk of Dying From Prostate Cancer

One of the greatest benefits of staging is that it provides insight into the disease’s seriousness, which is one of the most important factors in determining optimal treatment. Treatment intensity should be commensurate with the disease’s aggressiveness. Mild cancers deserve mild treatment. Aggressive cancers require aggressive therapy.

Enduring treatment-related side effects is unacceptable if the cancer is mild, whereas more side effects can be accepted when life-threatening disease is present. Table 1 shows how much the risk of mortality varies between stages.

Table 1: Risk of Dying Per Stage

Stage of Blue	Degree of Treatment Intensity Recommended	Risk of Dying	% of Newly-Diagnosed per Stage
Sky	None	<1%	50%
Teal	Moderate	2%	30%
Azure	Maximal	5%	10%
Indigo	Mod. To Max.	<50%	0%
Royal	Maximal	>50%	10%

Important Note: The table above shows that the degree of treatment intensity recommended for 80 percent of men who are newly-diagnosed (Sky and Teal) is either moderate or none.

The Timing of Mortality From Prostate Cancer                                                  

Prostate cancer behaves very differently from other cancers, especially in how slowly it grows. For example, mortality from lung cancer or pancreatic cancer may occur within the first year of diagnosis. Our familiarity with these terrible types of cancer explains why the word “cancer” causes so much consternation. Cancer, we think, equates with imminent death. But look how the statistics in Table 2 show how differently prostate cancer behaves.

Table 2: Survival Rates for Newly-Diagnosed Prostate Cancer

	Survival Rate	Original Date of Diagnosis
5 Year	99%	2012
10 Year	98%	2007
15 Year	94%	2002
More than 15 years	86%	Late 1990s

Consider that survival rates can only be determined by the passage of time; 10-year mortality can only be calculated in men who were diagnosed back in 2007, and by today’s standards, treatment back then was antiquated. Therefore, the survival statistics that rely on older technology might not represent the prospects of a patient undergoing treatment today. Survival rates will continue to get better with time, and, if anything, men with slow-growing prostate cancer have time.

Other Staging Systems Are Incomplete

When men ask their doctors, “What stage am I?” they are usually unaware that there are multiple different staging systems in use. Let’s briefly review the other staging systems:

1. Clinical staging (A, B, C, and D) relates specifically to how the prostate feels on a digital rectal exam (DRE). This system was developed before PSA was invented and is used by surgeons to determine if the performance of a radical prostatectomy is acceptable (See Table 3).
2. Pathologic staging relates to the extent of the cancer determined by surgery or by a biopsy.
3. TNM Staging incorporates the information from both 1 and 2 as well as the information obtained from bone scans or CT scans.
4. Risk category staging, which divides newly diagnosed men into low, intermediate, and high-risk categories, uses information from 1 and 2 plus the PSA level.

Table 3: Clinical Stage (DRE Stage)

Stage	Description
T1:	Tumor that cannot be felt at all by DRE
T2:	Tumor confined within the prostate T2a: Tumor in < 50% of one lobe T2b: Tumor in > 50% of one lobe but not both lobes T2c: Tumor felt in both lobes
T3:	Tumor that extends through the prostate capsule T3a: Extracapsular extension T3b: Tumor that invades seminal vesicle(s)
T4:	Tumor that invades the rectum or bladder

Components of the Stages of Blue

The Stage of Blue system utilizes all the other staging systems (1, 2, 3 and 4 listed above), plus it incorporates information about whether previous surgery or radiation has been performed.

• Digital rectal exam: Normal vs. nodule vs. mass  
• Gleason score: 6 vs. 7 vs. 8-10
• PSA: <10 vs. 10-20 vs. over 20
• Biopsy cores: Few vs. a moderate amount vs. many
• Previous therapy: Yes vs. no
• Imaging: Extent of disease, whether it is in lymph nodes or bones

You can determine your stage online at the PCRI website by answering a short question quiz at stagingprostatecancer.org.

What’s Wrong With the Risk-Category Staging System?

The risk-category staging system, which is constituted by the top three components in the bulleted list above, doesn’t include many of the important new staging factors that further enhance the accuracy of staging:

• Multiparametric-MRI findings
• The percentage of biopsy-cores that contain cancer
• PET scan information

On top of that, the risk-category system doesn’t include men who have relapsed disease, men with hormone resistance, or men with metastases in the bones.

Once You Know Your Stage, Which Treatment Is Best?

The main value of knowing one’s stage is that it allows patients and doctors to zero in on the most sensible treatment options. In the remainder of this article, some stage-specific treatment options are presented for each of the stages.

Sky

Since Sky (Low-Risk) is a relatively harmless entity, and since we now know that Gleason 6 never metastasizes, labeling it a “cancer” is a complete misnomer. Ideally, Sky would be named as a benign tumor rather than a cancer. Therefore, all of the three variations of Sky, (Low, Basic and High)are managed with active surveillance. The biggest risk for men in Sky is the failure to detect occult higher-grade disease. So diligent scanning with multiparametric MRI at an experienced cancer center is prudent.

Teal

Teal (Intermediate-Risk) is a low-grade condition with excellent long-term survival prospects. However, most men require treatment. The exception is Low-Teal, for which active surveillance is acceptable. To qualify as Low-Teal the Gleason must be 3+4=7, not 4+3=7, the amount of Grade 4 in the biopsy must be less than 20 percent, only 3 or fewer biopsy cores can contain cancer, no core can be more than 50 percent replaced with cancer, and the rest of the finding must be like Sky.

Basic-Teal has more cores containing cancer than Low-Teal, but still fewer than 50 present. Men with Basic-Teal are reasonable candidates for single agent therapy with almost any of the modern treatment alternatives, including seed implants, IMRT, Proton therapy, SBRT, hormone therapy, and surgery.

High-Teal encompasses any set of criteria for a Teal patient that does not fit into Low or Basic. High-Teal is more aggressive and should be treated with combination therapy that includes IMRT, seeds, and a four-to-six-month course of hormone therapy.

Azure

Azure (High-Risk) also contains three subtypes. Low-Azure is Gleason 4+4=8 with two or fewer positive biopsy cores, no biopsy core more than 50% involved with cancer, and all other factors like Sky. Men with Low-Azure are treated the same way as High-Teal.

Basic-Azure is the most common type of Azure and represents anything in the Azure category that fails to meet the criteria of Low or High. Basic-Azureis treated with radiation, seeds, and hormone therapy for 18 months.

High-Azure is defined as one or more of the following: PSA over 40, Gleason 9 or 10, more than 50 percent biopsy cores, or cancer in the seminal vesicles or pelvic nodes. High-Azure is treated the same as Basic-Azure, though possibly with the addition of Zytiga, Xtandi, or Taxotere.

Indigo

Indigo is defined as a cancer relapse after surgery or radiation. Whether Indigo is Low, Basic or High is determined by the likelihood of cancer spread into the pelvic nodes. Low-Indigo means the risk is low. To qualify as Low-Indigo, the PSA has to be < 0.5 after previous surgery or < 5.0 after previous radiation. Also, the PSA doubling time must be > 8 months.  In addition, the original Stage of Blue prior to surgery or radiation had to have been Sky or Teal. Treatment for Low-Indigo may consist of radiation (after previous surgery) or salvage cryotherapy (after previous radiation).

Basic-Indigo means that scans and pathology findings show no metastasized cells (known as mets), but the favorable criteria cited above for Low-Indigo are unmet. In other words, one or more of a variety of factors suggest that microscopic pelvic mets are more likely to be present. For Basic-Indigo, aggressive combination therapy with radiation to the pelvic nodes and hormonal therapy should be used.

High-Indigo means mets are proven to exist in the pelvic lymph nodes. The treatment of High-Indigo is the same as Basic-Indigo except that additional therapy with Zytiga, Xtandi, or Taxotere can be considered.

Royal

Men in Royal either have hormonal-resistance (a rising PSA with low testosterone) or metastases beyond or outside of the pelvic nodes (or both). Low-Royal is “pure” hormone resistance without any detectable metastases. These men almost always have small amounts of metastatic disease but it may be impossible to detect with standard bone or CT scans. New, more powerful PET scans such as Axumin, PSMA, or Carbon 11 may be required to find the metastases. Once the metastases are located, treatment will be the same as Basic-Royal.

Basic-Royal is the unequivocal presence of metastatic disease (outside the pelvis) but the total number of metastases is five or less. Treatment for Basic-Royal is a combination of SBRT or IMRT to all sites of known disease, Provenge immunotherapy, plus Zytiga or Xtandi.

High-Royal means that more than five metastases have been detected. SBRT or IMRT with so many metastases is usually not practical. When the disease is not rapidly progressive or painful, treatment should consist of Provenge followed by Zytiga or Xtandi. Painful or rapidly progressive disease should be treated with Taxotere.

Prostate Cancer for Beginners

Prostate Cancer Basics

Whether you or someone you know has been recently diagnosed with prostate cancer or you are simply interested in learning more about this important disease, there are three key questions that need to be answered.

What Is the Prostate?

The prostate is a small, walnut-sized gland that exists only in men. It is situated just below the bladder and just in front of the rectum in the lower pelvis.

The bladder acts as a storage area for urine. When the bladder is emptied, the urine travels through a thin tube called the urethra to the penis and then out. The very beginning of the urethra as it leaves the bladder passes directly through the prostate. This fact accounts for why so many men with either prostate cancer or BPH (benign prostatic hyperplasia) develop trouble urinating. As the prostate enlarges, the urethra is pinched off, leaving a smaller tube to carry urine from the bladder to outside the body.

The prostate’s primary function is to produce much of the fluid that makes up semen. Semen acts to protect sperm as it makes its way out of the body.

The prostate is present from before birth and grows in response to male hormones such as testosterone. Blocking the production or effects of these hormones is one of the primary treatment options for prostate cancer.

What Is Cancer?

Cancer is most simply explained as cells in a certain part of the body that have started to grow in an out-of-control and unregulated fashion.

The human body is made up of billions of tiny units called cells. These are the smallest structures in the body that can be considered to be living. They can only be seen under high-powered microscopes. Cells normally go through a life cycle of growth, division, and death. When this occurs in an orderly fashion, cells are created and die in roughly equal numbers. They also normally stay confined to the area of the body in which they were meant to be.

Unfortunately, certain cells sometimes begin to multiply much faster than they die. When this happens, these abnormal cells squeeze out nearby normal cells. These abnormal cancerous cells can also spread outside of their original site in the body and spread to other areas. When cancer from one body site has spread to other areas of the body, the cancer can be said to have “metastasized". This is always an unfortunate occurrence as cancer that has spread is much harder to treat in general.

A cancer is named after its original site in the body. For example, prostate cancer, even if it were to spread to the bones or to the colon would still be called prostate cancer and not bone or colon cancer. This would more appropriately be called “prostate cancer with metastasis to the bone.”

All types of cancer are different. For example, prostate cancer is very different from lung cancer. The two are caused by different factors, diagnosed in different ways, and treated differently. Regardless of the type of cancer, the underlying problem is the unregulated and abnormal growth of the cells in that part of the body.

What Is Prostate Cancer?

Since cancer is the uncontrolled and abnormal growth of cells in a certain area of the body, prostate cancer is simply the uncontrolled and abnormal growth of cells in the prostate.

Some men have BPH (benign prostatic hyperplasia). This is often confused with prostate cancer. With BPH, prostate cells multiply faster than they should. This causes the prostate to enlarge and the patient to develop difficulty urinating. With prostate cancer, the cells not only multiply faster, but also behave abnormally by spreading outside of the prostate if not caught in time. BPH is not cancer but can show some of the same symptoms.

The prostate is made up of many different types of cells. The gland cells (those cells that actually work to produce the fluid that is released into the semen) however, are nearly always the cells that become cancerous. The technical medical term for cancer that arises from gland cells is adenocarcinoma. Thus, the technical term for prostate cancer is prostate (or prostatic) adenocarcinoma.

Early detection, prompt diagnosis, and effective treatment are the mainstays of good prostate cancer care.

A better life for England's teachers...

Diving back into English Culture

After a long time away, I deal with returning to England in much the same way as I enter a cold swimming pool. There’s no point in dipping my toes first, the whole process is agonisingly slow, and I’m afraid that one day I won’t be able to do it; such is the change in a country I once knew so well. No, I march straight down to the deep end, take a deep breath and dive into my hometown agricultural show; English again in a flash!

Penrith is and has been for centuries, a key hub in the Cumbrian farming community with tractors, sheep and horses passing through town as regular as tourist caravans. It’s as old as towns get, with evidence of a settlement dating back to 500 BC and was the ancient capital of Cumberland. Our house is relatively modern, dating back to around 1680 and on a back street that used to be the main London Road. 

Agricultural shows are held throughout England from around June to September, and the date is set in stone regardless of the weather. Bad luck on the day could see a complete washout, or at best everyone wading through muddy fields, steam rising from the rich mix of soil and dung, an almost creamy taste to the air if you allow the imagination to flow!

In the north of England, maybe it’s the frequent memories of all those ugly days that makes it oh so wonderful when, as with this year, the Penrith Show was blessed with sunshine.

Although all these shows vary in size, they carry a very common theme throughout and every town/village holds great pride in putting together an amazing catalogue of events where there really is, ‘something for everyone.’

The most obvious on display, just through sheer size, are the horses, and these range from mighty shires capable of pulling massive loads, to tiny ponies smaller than some dogs! The jumping events are a spawning ground with young country folk trying to outgun each other, not just over the sticks but in the fashion stakes too; all farmers seemingly addicted to the principle of strength through breeding!

Massive bulls, cows, sheep, pigs and then to the dogs, rabbits and chickens, many smaller than starlings. A prize-winning cow can produce, on average, 8 gallons of milk per day in exchange for 100 pounds of feed, which can include grain, silage, hay, soybean meal, plus vitamins and minerals. You’ll see these interesting facts on display everywhere and what a great idea, getting everyone interested in so much often taken for granted.

If you’re a southerner, you might be excused for thinking there are two or three varieties of sheep, but I lost count at this year’s show. The rams seemed out of proportion with reality, some as large as small bulls and showing no fear of anyone. Others, small and timid, huddled in the corner of their pens, terrified of the surroundings looking, well, as bewildered as a sheep can. The same for the pigs really but they seemed far harder to keep clean, farmers running ahead of the judges, tools at the ready, continually trying to clean up the dung before the huge animals could joyously roll around in it, savouring every steaming squelch!

The sheepdogs always pulled a big crowd, their skills looking vastly enhanced against an animal with similar intelligence to a pigeon, but unable to fly. But you could bring your pet dog and win prizes too, as long as they would obey the simplest of instructions and not try to eat or become over-acquainted with the other dogs! Cats? I didn’t see any all day; maybe I missed the ‘cat tent.’

Poultry? A sea of chickens, ducks, geese and every other feathered thing you could think of under one giant marquee, but not just birds, their eggs too! I made the mistake of asking a judge just how they decided on the best egg; I was still glued 10 minutes later! Size, shape, colour, uniformity, balance, and then when broken, whether the yolk sits centrally to the white, the colour, volume, opacity, shell thickness…it went on, and on…then, all 3 or even 6 had to match; synchronised eggs! Judges were vastly experienced and travelled hundreds of miles to preside over these fiercely contested events!

At the Penrith Show, you soon begin to realise that you can enter almost anything for a prize, not just a horse, rabbit or pig but peas, dolls, strawberries, bread, knitwear, wine, jam…even recycled junk models; such is the nature of this special summer day.

As a child, I had a pet chicken called ‘snowy’ who followed me around the yard everywhere. One day I noticed she was missing, so at dinner, while tucking in, I asked, “Grandma, where’s Snowy?” She told me that Snowy had gone on holiday, and I accepted that, after all, we all needed a holiday. Even the white feathers in the yard hadn’t given me the obvious clue that I was sadly eating my best friend! Well, nothing much has changed, because kids at the show petting rabbits, chickens and sheep seemed oblivious to any connection between them and the food/butcher’s stalls around the ground. I feel it more open and honest in Thailand, with children well aware from an early age that they are actually eating animals and a clearer relationship with their food. 

Shouting, grunting, cheering and clapping ahead? That had to be the Cumberland Wrestling! A simple rough circle scored on the grass and two willing opponents who are told to, “tekk hod!”

It’s strength and skill from there on to try and get the other person either on their back, out of the ring or break their hold, and it’s best-of-three. The crowd never get bored as each bout lasts around 3 minutes and there’s no break between the next pair coming on. Under 12’s, under 15’s, under 18’s then it goes by weight, up to 12 stones and then ‘any weight’ where the giants or ‘plumb uglae ans’ come out. In recent years they started a ‘Women’s Open’ which is proving extremely popular with the men and this year took place in the only torrential downpour, everyone watching from the packed beer tent, exploding in rapturous applause as many a country-lass displayed their art in gladiatorial style.

Hospitality tents dotted around with free canapés and champagne if you happened to be a customer, but plenty of hot-dogs, burgers, tea and coffee for the commoners. The biggest surprise of the day…”Thai Food” cooked in a wok by a lovely woman from central Thailand, and as friendly as all Thai’s are! I practiced my little Thai to greet her and then quickly broke into English just in case she asked me anything! Had I seen that five years ago I would have dreamt of living in that wonderful country, now three years in I feel so lucky, it’s a reality.

The display of vintage tractors was a must because they gave contrast to the new equipment available to today’s farmers, ranging from hi-tech quad bikes with GPS to monster combine harvesters, more at home in a Transformers movie. I thought back to my Grandad, who in 1935 had won the All Ireland Championship for turning a straight furrow with a horse and single plough and wished he could be there to see how easy life would get. Tens of thousands once worked the land in Cumbria, whole villages in full employment, but machines have replaced them all, strawberries being the final challenge.

A breathtaking day, all in all, where the local community met with those who put the food on our plates but rarely see eye to eye with us, ‘townies,’ who endlessly complain about animal rights, chemical pollution, muck on the roads and most other things that make ‘country-folk’ so delightfully different!

My Medical at BNH Hospital, Bangkok...

A good friend of mine died recently; that often triggers thoughts on our own wellbeing!

I feel OK but what’s going on inside me? Wouldn’t it be worth finding out?

At 9 am on a Monday morning, I sprinted into reception at BNH Hospital at Silom, a deluge of a tropical storm slapping me one last time as I was washed through the door! I’m familiar with the hospital and went straight to the 4^th floor where I was warmly welcomed and checked in. I wasn’t sure what to expect, my last medical had been decades ago; however, I was about to be pleasantly surprised! 
The process was explained to me very clearly, and I was assured that I’d be looked after throughout.

So we started, first the basics, blood pressure, height, weight, sight test, ears and then a blood sample, which would provide a massive amount of information later. I then had a chest x-ray, angiogram (heart), upper and lower ultra-sound scan before giving a urine sample.

After that, it was off to spend my free voucher in the café and have fun, just having fasted for 10 hours, I was ready!

An hour later I was back in front of a very pleasant doctor for my results, and was amazed at the amount of information given, but also assured that it would be all e-mailed to me as a report later.

My weight was fine for my body height, and all other indications were that I was in fairly good health. My lungs were clear, my heart was strong, and most other areas and organs were all good. My liver though had two small cysts, currently considered harmless but, “worth keeping an eye on next time.” My gallbladder had a lot of stones in, some as big as 5mm but as it wasn’t causing me a problem, they suggested I book in to have it out later in the year, rather than waiting for it to flare up. My bad cholesterol was a little on the high side so need to be more careful with what I eat, and as my uric acid was also a bit high, I need to drink more water.

So, all in all, at 66 years old I left the hospital bouncing with joy that day, relieved that I had nothing seriously wrong with me and grateful that the advice given to me could help prevent my few minor ailments from becoming major!

The piece of mind alone was worth what I paid that day, and sure enough, the e-mail report arrived the day after, confirming everything.

You’d do it for your car, so why not yourself?