Prostate Cancer: Understanding Your Pathology Report After Biopsy

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Prostate cancer starts in the prostate, a small organ that sits below the bladder in men. The prostate produces part of the fluid in semen. Almost all prostate cancers begin in the cells lining its small glands.

As a prostate cancer grows, it can spread into the supporting tissue around those glands. It can reach the outer edge of the gland and pass beyond it. It can also travel along nerves, and it can reach lymph nodes in the pelvis. Less often, it spreads to bone or to other organs. That is called metastasis.

This article explains the pathology report created after a needle biopsy of the prostate. A needle biopsy takes thin cylinders of tissue, called cores, from different parts of the gland. The needle may be passed through the wall of the rectum, or through the skin between the scrotum and the anus.

Why your pathology report looks like a checklist

Most pathology reports for prostate cancer include a section that looks like a list of headings, each followed by a short answer. This is called a synoptic report. It follows a standard checklist published by the College of American Pathologists (CAP). Laboratories across North America, Europe, and much of the world use the same one.

For prostate biopsies, CAP recommends this checklist rather than requiring it. Most laboratories use it, but some write the same findings as ordinary paragraphs instead. If your report reads as prose rather than as a list, every item described in this article should still be somewhere in it.

Prostate biopsy reports are built differently from every other cancer report, and this is worth understanding before you read yours. A prostate biopsy is not one piece of tissue. It usually consists of 12 to 14 cores, taken from named parts of the gland and sent to the laboratory in separately labeled containers. The pathologist examines each container and reports on it individually.

Because of that, the checklist comes in two versions, and your report may use one or both.

Specimen level — A separate summary for each container that contained cancer. If cancer was found in 5 of your 12 containers, there may be 5 of these summaries. Each has its own grade and its own measurement.
Case level — A single summary for the biopsy as a whole. It pulls the findings from every container together into one set of answers.

One checklist covers every carcinoma that arises in the prostate. Nearly all of them are acinar adenocarcinoma, the ordinary type. The others are uncommon, and they include ductal adenocarcinoma, the neuroendocrine carcinomas, and rare squamous and basal cell tumors. All are covered by the same form.

Because one checklist covers all of these tumors, your report may list items that do not apply to your situation. An item asking about the seminal vesicle applies only if seminal vesicle tissue happened to be sampled. An item asking about treatment effect applies only to men treated before the biopsy.

When an item does not apply, the report will say something like “not identified,” “not applicable,” or “cannot be determined.” Seeing those phrases does not mean something was missed. It usually means the feature was looked for and was not there.

This checklist is used for needle biopsies only. If your prostate has since been removed, that operation is reported on a different checklist, covered in our guide to your radical prostatectomy pathology report. Tissue removed to relieve urinary blockage, called a TURP, has its own checklist as well. Lymphoma, sarcoma, and urothelial carcinoma each have their own, so a report on one of those will not match the items described here.

This article covers every item on the checklist, in the order you will find them on your report. Reading it will help you understand what each term means and why it matters for your care.

How is the diagnosis made?

A pathologist diagnoses prostate cancer by examining tissue from the prostate under a microscope. The tissue is obtained by needle biopsy, in which a thin hollow needle removes a core of tissue. Most men are referred for biopsy because of a raised prostate-specific antigen (PSA) level. Others are referred because of an abnormal finding on physical examination, or a suspicious area seen on MRI.

Under the microscope, the pathologist looks for glands that have lost their normal structure. Normal prostate glands are lined by two layers of cells. The inner layer produces the prostate’s secretions, and the outer layer is made of basal cells. In cancer, the basal cell layer is gone, the glands become small and crowded, and the nuclei enlarge and develop prominent nucleoli.

A small focus of cancer can be difficult to separate from several harmless conditions that mimic it. When that happens, the pathologist performs immunohistochemistry, a test that uses colored stains to show specific proteins in tissue. One combination is used most often. Stains for p63 and high molecular weight cytokeratin mark the basal cells, which are lost in cancer. A stain for AMACR is usually positive in cancer and negative in normal glands.

After prostate cancer is confirmed, imaging may be performed to assess whether it has spread beyond the gland. Depending on your PSA level and your grade, this may include MRI of the prostate, a bone scan, CT, or a PSMA PET scan. Men with low-grade, low-volume cancer often need no imaging at all. The pathology report describes what was found in the cores that were removed; imaging describes the rest of the body.

The type of biopsy: systematic, targeted, or both

The case level summary of a prostate biopsy report begins by naming how the biopsy was performed. The answer explains why your cores are labeled the way they are. More than one answer can be selected.

Systematic biopsy — Cores are taken in a standard pattern that samples the whole gland, whether or not imaging showed anything abnormal. This is the traditional approach and typically produces 12 to 14 cores.
Targeted biopsy — Cores are aimed at an area that looked suspicious on MRI. The MRI images are usually fused with live ultrasound during the procedure. These cores are labeled separately, often as “MRI-guided” or with a target number.
Other — A sampling approach that does not match either of the above, which the report describes.

Many men now have a systematic biopsy and a targeted biopsy at the same sitting, and both answers are then selected. This combination is the most informative, because each approach finds some cancers the other misses.

Where the cancer was found

Your prostate biopsy report names the location of every container that contained cancer. Locations are given by side and by level within the gland, so a report might list right base, left mid, or left apex lateral. The base is the top of the prostate near the bladder. The apex is the bottom, near the urethra and the muscles that control urination. The mid is between them.

Several other labels appear. Lateral and medial describe how far from the midline the core was taken. The transition zone is the inner part of the gland surrounding the urethra, which enlarges with age in benign prostatic hyperplasia. MRI-guided cores and other targeted cores are labeled individually, each with its own identifier.

These locations matter for what comes next. They tell your surgeon or radiation oncologist which parts of the gland are involved, and whether the cancer is on one side or both. They also show whether it sits near structures that affect surgical planning. Two of those matter most: the nerves responsible for erections, and the sphincter muscle at the apex. If treating only part of the gland is being considered, this map is what that decision is built on.

Types of prostate cancer (histologic type)

Histologic type describes what the prostate cancer looks like under the microscope. Pathologists assign the type using the World Health Organization (WHO) classification. Almost all prostate cancers are one type. The checklist names the others because they exist and must be recorded when they occur, not because they are common. More than one type can be selected when a tumor contains more than one.

Acinar adenocarcinoma

Acinar adenocarcinoma accounts for more than 95 out of every 100 prostate cancers. Reports describe it as conventional or usual type. If your report does not name a type at all, or simply says adenocarcinoma, this is what you have.

It arises from the cells lining the small glands of the prostate, which are called acini. It grows as crowded small glands that infiltrate between the normal structures of the gland. Nearly everything else on your report was developed for and validated on this type, including the grade, the measurements, and the treatment options that follow from them.

Acinar adenocarcinoma sometimes shows an unusual appearance that the pathologist will name. These are patterns within the same cancer rather than separate diseases. None of them changes the basic approach to treatment.

Signet ring-like cell pattern — The cells contain a clear space that pushes the nucleus to one side. That gives them the look of a ring with a stone.
Pleomorphic giant cell pattern — The cells are large and vary greatly in size and shape.
Sarcomatoid pattern — The cells become spindle-shaped and resemble the cells of a soft tissue tumor.
Prostatic intraepithelial neoplasia-like pattern — The cancer glands resemble a noncancerous change called high-grade PIN, which makes the diagnosis harder to reach.

Because a biopsy samples only part of the tumor, the pathologist may describe a pattern rather than name it outright. A report may say adenocarcinoma with signet ring-like cell features instead of assigning the pattern as a diagnosis.

Other types of prostate cancer

Types other than acinar adenocarcinoma make up well under 5 in every 100 prostate cancers combined. They are named on the report because several of them are managed differently.

Ductal adenocarcinoma — Tall column-shaped cells forming finger-like fronds and larger glands. It tends to be found at a more advanced stage, may produce less PSA, and is generally managed as higher-risk disease.
Isolated intraductal carcinoma — Cancer cells filling and expanding existing prostate ducts, with the basal cell layer still present, and no ordinary invasive cancer alongside. It is rare as the only finding, and it has its own section below.
Adenocarcinoma with neuroendocrine differentiation — An otherwise ordinary adenocarcinoma containing scattered hormone-producing cells. It is usually managed as adenocarcinoma.
Well-differentiated neuroendocrine tumor — A rare, slow-growing neuroendocrine tumor of the prostate.
Small cell neuroendocrine carcinoma and large cell neuroendocrine carcinoma — Fast-growing cancers made of neuroendocrine cells. They often produce little or no PSA and do not respond to hormone-blocking therapy. Naming them changes the treatment plan entirely, because chemotherapy is used instead.
Squamous cell carcinoma and adenosquamous carcinoma — Rare cancers made partly or entirely of flat, scale-like cells. They do not respond to hormone-blocking therapy.
Basal cell carcinoma, also called adenoid cystic carcinoma — A rare tumor arising from the basal cell layer rather than the secretory cells. Most behave in a limited way, though some spread locally.
Other histologic type not listed — A type outside the list above, which the report names.
Carcinoma, type cannot be determined — The tissue available did not allow the type to be settled, and the report explains why.

The neuroendocrine carcinomas sometimes appear in men treated with hormone-blocking therapy for many years for an ordinary prostate cancer. A repeat biopsy is what identifies the change. Some reports add a histologic type comment, which is free text the pathologist uses to explain an unusual feature.

Histologic grade: Gleason score and Grade Group

Histologic grade is the most important number on a prostate cancer biopsy report. It describes how far the cancer glands have departed from the normal architecture of the prostate. It predicts behavior better than any other single feature on the report. Prostate cancer uses its own grading system, which works differently from those used for other cancers.

Gleason patterns

The pathologist assigns a Gleason pattern to the cancer based on how its glands are arranged. Only three patterns are in current use.

Pattern 3 — The cancer still forms separate, well-shaped glands. This is the least concerning pattern.
Pattern 4 — The glands are poorly formed, fused together, arranged in sheets with punched-out holes, or shaped like a ball on a stalk.
Pattern 5 — The cancer has largely stopped making glands. It grows as sheets, cords, or single cells, sometimes with dead tissue in the center.

Patterns 1 and 2 belonged to the original system and are no longer assigned. That is why the lowest score reported today is 6 rather than 2.

Gleason score

The Gleason score adds two pattern numbers together. On a biopsy, the first number is the pattern that makes up most of the cancer. The second is the worst remaining pattern present. If only one pattern is present, it is doubled.

That is why the score is written as a sum. A score of 3+4=7 means mostly pattern 3 with some pattern 4. A score of 4+3=7 means mostly pattern 4 with some pattern 3. Both add to 7, but they are not the same cancer, and 4+3 carries the higher risk.

Two rules shape the second number, and they are not symmetrical. A small amount of a higher pattern is always reported, even below 5 percent of the cancer. A small amount of a lower pattern is not. When three patterns are present, the pathologist combines the most common one with the worst one.

Grade Group

Because the Gleason score no longer uses the bottom half of its own scale, the scores are also reported as a Grade Group from 1 to 5. Grade Group is now the primary way prostate cancer grade is described, and your report should give both.

Grade Group 1 (Gleason score 3+3=6) — Only well-formed glands. This is the lowest grade that can be diagnosed. Cancers in this group very rarely spread, and most men with Grade Group 1 disease are offered monitoring rather than immediate treatment.
Grade Group 2 (Gleason score 3+4=7) — Mostly well-formed glands, with a smaller amount of poorly formed, fused, or sieve-like glands.
Grade Group 3 (Gleason score 4+3=7) — Mostly poorly formed, fused, or sieve-like glands, with a smaller amount of well-formed glands.
Grade Group 4 (Gleason score 4+4=8, 3+5=8, or 5+3=8) — Poorly formed glands throughout. It also covers a mix of well-formed glands and areas making no glands at all.
Grade Group 5 (Gleason score 4+5=9, 5+4=9, or 5+5=10) — Little or no gland formation, often with dead tissue. This is the highest grade and the group most likely to spread.

A Gleason score of 6 is not a 6 out of 10. It is the bottom of a scale that runs from 6 to 10, and Grade Group 1 is the least concerning result that can be reported. Many men who see the number 6 assume their cancer is halfway to the worst possible, and it is not.

Percentage of pattern 4

When the Gleason score is 7, your report should also give the proportion of the cancer made up of pattern 4. It is given as a range. For a score of 3+4, the ranges are 5 percent or less, then 10-point bands up to greater than 40 percent. For a score of 4+3, the ranges run from less than 61 percent up to greater than 90 percent.

This matters because Gleason score 7 covers a wide span of risk. A cancer that is 5 percent pattern 4 behaves differently from one that is 40 percent pattern 4. Men with only a small amount of pattern 4 may still be candidates for monitoring rather than treatment.

Two limits apply. When the cancer occupies less than 10 percent of a core, the focus may be too small to give a reliable percentage, and the report says so. At the specimen level, the percentage may be marked “not applicable” for one container when another container in the same biopsy holds a Gleason score of 8 or higher. When the score is 8 or above, the percentages of pattern 4 and pattern 5 may be given as optional extra information.

When no grade is given

Your report may state that the grade is not applicable or cannot be assessed. There are three common reasons, and none of them is an error.

Tumor microfocus — The cancer in that container is a few glands, too small to grade confidently. A number that might be wrong could change your treatment, so the pathologist reports the finding without one. Your report records this as a separate answer.
Cancer seen only around a nerve — When the only cancer in a core surrounds a nerve, it is not graded.
Previous treatment — Hormone-blocking therapy and radiation change the appearance of prostate cancer cells so much that the Gleason system no longer applies.

Cribriform glands

Cribriform glands are sheets of prostate cancer cells punched through with round holes, like a sieve. They are one of the four architectures that count as Gleason pattern 4. Your report states separately whether they are present, and this item is completed only when the Gleason score is 7 or 8.

They are singled out for a reason. Among the pattern 4 architectures, cribriform growth is the one most consistently linked to a higher chance of the cancer spreading and of returning after treatment. Two cancers can both be Grade Group 2, and the one with cribriform glands carries the higher risk. Its presence often moves a man away from monitoring and toward treatment, so this single line can change what is discussed with you.

Your report gives one of five answers: not applicable, not identified, present, equivocal, or cannot be determined. Equivocal means the pathologist saw glands that come close to the definition without meeting it, and the report explains what was seen.

Intraductal carcinoma

Intraductal carcinoma of the prostate, shortened to IDC, means cancer cells are filling and expanding existing prostate ducts. The normal basal cell layer around those ducts is still in place. On a biopsy it is almost always found alongside ordinary invasive cancer, and finding it on its own is rare. The report states not identified, present, or cannot be determined.

Intraductal carcinoma is recorded because it carries information of its own. It is strongly associated with high-grade, high-volume cancer elsewhere in the gland, even when the cores show only a small amount of cancer. It is also associated with a higher risk of the cancer returning after treatment. It is more common in men who carry an inherited BRCA2 gene change, so its presence may prompt a referral for genetic testing.

Where intraductal carcinoma is present, the report states whether it was incorporated into the grade. Two pathology organizations disagree on this point. One recommends including it when assigning the Gleason score, and the other recommends leaving it out. Neither approach is wrong. The report names which one was used, so that your treating physician can read the grade correctly.

Pure intraductal carcinoma, with no invasive cancer at all, is not given a Gleason score under either approach.

Grade for the whole case: highest, composite, and global

When prostate cancer is found in more than one container, and those containers have different grades, the case level summary may give more than one overall grade. Seeing several different Grade Groups on a single report is expected, not a contradiction.

Highest grade — The grade of the single worst container. This is the number most often used to guide treatment, because the worst part of the cancer drives the outcome. Your report may also name which sites carried it.
Composite grade — A combined grade for cores that sit next to one another and appear to be sampling the same tumor. It avoids diluting a significant tumor by averaging it with unrelated low-grade cancer elsewhere, and it matches the grade found at surgery more closely than the alternatives.
Global grade — A combined grade calculated across all positive cores, regardless of where in the gland they sit.
Targeted biopsy grade — The grade of an MRI-targeted lesion, reported separately for each target, with its own identifier. Global grade is not used for a targeted lesion, because the grade of that lesion is already a composite.
Combined systematic and targeted grade — An optional single grade drawing on both kinds of core, given when the systematic and targeted results differ.

The overall grade is completed only when two or more containers hold cancer with different Gleason scores. Otherwise it is marked not applicable. Where an overall grade is given, the report states whether the composite or the global method was used.

Tumor quantitation: how much cancer was found

Along with grade, the amount of prostate cancer in the biopsy is what determines whether treatment is discussed now or the cancer can be monitored. Your report measures it in several ways, some for each container and some for the biopsy as a whole.

Total number of cores and number of positive cores — For example, cancer in 3 of 12 cores. This ratio gives a rough sense of how widely the cancer is spread through the gland. Where the cores arrived in fragments, the report may say the count cannot be determined.
Percentage of the core involved — How much of a positive core is made up of cancer, given as a range. The bands run from less than 1 percent, through 10-point steps, to greater than 90 percent. The specimen level summary gives this for each core. The case level summary gives the greatest percentage found in any single core.
Length of cancer in millimeters — A direct measurement of the cancer along the core, reported alongside or instead of the percentage. Very small amounts may be given as less than 1 millimeter.
Measurement technique — Whether the cancer sat in one continuous stretch, or in several separate spots measured as a single span, or in several separate spots measured and added together.
Totals for the whole biopsy — Three optional figures. The percentage of all the prostate tissue involved by cancer, the total millimeters of cancer, and the total millimeters of core tissue examined.

The measurement technique has real consequences. Take a core 20 millimeters long with cancer at each end and normal tissue in between. The involvement can be described as 100 percent measured end to end, or as 10 percent if only the cancer itself is added up. Both descriptions are honest, and the difference can decide whether you meet the criteria for monitoring. Many programs exclude men with any core more than 50 percent involved.

Most studies find that measuring end to end matches what is found at surgery more closely, because separate spots in one core usually belong to the same tumor. Some reports give both numbers. If your report gives only one, or the number looks surprisingly high, you can ask which method was used.

Periprostatic fat invasion

Periprostatic fat is the fatty tissue surrounding the outside of the prostate. There is essentially no fat inside the gland itself. When a needle biopsy contains fat with prostate cancer growing in it, the cancer has reached beyond the edge of the gland. This is called extraprostatic extension, and on a biopsy it means the cancer is at least stage T3a.

The report states not identified, present, equivocal, or cannot be determined. This finding is uncommon on biopsy, because the needle targets the gland rather than its outer surface. When it does appear, it is usually accompanied by high-grade cancer. It generally moves a man into a higher risk category, and away from monitoring or from surgery alone.

Seminal vesicle and ejaculatory duct invasion

The seminal vesicles are two small glands sitting behind and above the prostate that contribute fluid to semen. Prostate cancer growing into the muscular wall of a seminal vesicle indicates stage T3b disease, which affects treatment planning considerably. The report states not identified, present, equivocal, or cannot be determined.

One qualification applies, and your report may carry a comment about it. Only the part of the seminal vesicle lying outside the prostate counts for staging. Seminal vesicle tissue is sometimes picked up unintentionally during a biopsy, and that tissue usually comes from the part running through the gland. Cancer there does not mean stage T3b.

Telling seminal vesicle from ejaculatory duct under the microscope can also be difficult, which is why the specimen level checklist names the two together. When the pathologist cannot be certain, the report says so. That comment exists specifically to stop the cancer being staged higher than it should be.

Lymphatic and vascular invasion

This item records whether prostate cancer cells were seen inside small blood vessels or lymphatic channels. These vessels are one route by which prostate cancer reaches lymph nodes and bone, so finding cells inside one indicates they have gained access to that route. It does not mean the cancer has spread. The current checklist calls this lymphatic and vascular invasion; older reports call the same finding lymphovascular invasion.

The report states not identified, present, equivocal, or cannot be determined. This finding is uncommon in needle biopsies, and most reports state that it was not identified. When present, it is associated with higher-grade disease and a higher risk of the cancer returning. It is an optional item, so some reports do not address it at all.

Perineural invasion

Perineural invasion means prostate cancer cells were seen surrounding or tracking along a nerve. The prostate is densely supplied with nerves, and cancer commonly spreads along the outside of them. This is therefore one of the more frequent findings on a prostate biopsy report. The report states not identified or present.

What it means is less settled than the phrase suggests. Some studies find it predicts that cancer will be found outside the gland at surgery. Others find it adds nothing once grade and volume are taken into account. Guidelines do not treat it as a reason to change course on its own. Some monitoring programs do take it into account, and it may influence whether a surgeon attempts to spare the nerves near the tumor.

Treatment effect

This item applies only if you received hormone-blocking therapy or radiation before the biopsy. Both change the appearance of prostate cancer cells substantially. The cells shrink, develop clear or foamy cytoplasm, and lose the architecture that grading depends on.

No known presurgical therapy — No treatment was given beforehand. This is what most reports say.
Not identified — Treatment was given, but the tissue shows no sign of having responded.
Radiation therapy effect present — The changes typical of radiation are visible in the cancer.
Hormonal therapy effect present — The changes typical of hormone-blocking therapy are visible in the cancer.
Treatment effect present and new cancer present — Some of the cancer shows treatment change and some does not. The report calls the untreated part de novo cancer.
Cannot be determined — Treatment effect could not be assessed, and the report explains why.

The main consequence is that treated cancer is not given a Gleason score or Grade Group. The system was never designed for it, and a grade assigned to treated tissue would mislead. Where an area of cancer shows no treatment effect, that area can still be graded, and the report says so.

Other findings in the biopsy

The pathologist examines all of the tissue in every core, not only the cancer, and records other abnormalities found along the way. None of these is prostate cancer. Two of them can change what happens next.

High-grade prostatic intraepithelial neoplasia (PIN) — Abnormal cells lining otherwise normal ducts and glands, with the basal cell layer intact. It is considered a precursor to cancer. Repeat biopsy is now generally considered only when it is found at several sites, because the risk it carries has proved lower than once thought. Where cancer is already present, reporting it is optional and many reports leave it out.
Atypical intraductal proliferation (AIP) — Cells growing inside ducts that are more abnormal than high-grade PIN but fall short of intraductal carcinoma. It matters because it may be the edge of an intraductal carcinoma the needle did not fully sample. It is often a reason to biopsy again or to look more closely with imaging.
Atypical small acinar proliferation (ASAP) — A small group of glands suspicious for cancer but too few or too distorted for a firm diagnosis. This is not a diagnosis of cancer. It is a statement that the pathologist could not be certain, and it usually leads to a repeat biopsy. Cancer is found in a substantial proportion of men on the second attempt.
Inflammation — Immune cells in the prostate tissue, sometimes called prostatitis. It is common, usually causes no symptoms, and is not a precursor to cancer. It is recorded because inflammation can raise PSA and may explain the result that prompted your biopsy.
None identified — The tissue outside the cancer showed none of the findings above.

Anything else the pathologist saw is recorded under “other.” Benign prostatic hyperplasia is the entry patients see most often here. It means enlargement of the normal prostate gland and the tissue around it, and it is present in most men over 50. It is not cancer and does not become cancer, though it also raises PSA.

Why there is no stage on your biopsy report

Most cancer pathology reports end with a pathologic stage, written as pT and pN. A prostate biopsy report does not, and neither version of the checklist has a place for one. Its absence is not an omission.

Stage describes how far a cancer has spread, and a needle biopsy samples only a few thin cylinders from inside the gland. It cannot show how much of the prostate is involved, or whether the cancer has reached the lymph nodes. A pathologic stage cannot be assigned from it. The exceptions are the two findings described above. Periprostatic fat invasion and seminal vesicle invasion each establish a minimum stage when they appear.

Your treating physician assigns a clinical stage instead, based on physical examination, imaging, and PSA. That clinical stage is then combined with your Grade Group and your PSA level to place the cancer in a risk group. The names in use are low risk, favorable intermediate risk, unfavorable intermediate risk, and high risk.

Treatment discussions are based on the risk group rather than on the pathology report alone. This is also why two men with the same Grade Group can be given very different advice. You can read more in our article on TNM staging.

Biomarker and molecular testing

Biomarker testing looks for specific proteins and genes that determine which drugs are likely to work. A prostate biopsy report does not routinely include biomarker results, and neither version of the checklist has a section for them. CAP publishes no separate biomarker template for prostate cancer. Several tests may still be ordered on your biopsy tissue or your blood, and the results usually arrive separately.

Genomic classifiers — Tests such as Decipher, Prolaris, and the Oncotype DX Genomic Prostate Score measure the activity of a panel of genes in the tumor tissue. They refine the estimate of how the cancer is likely to behave, and are used most often when the choice between monitoring and treatment is finely balanced.
Inherited gene testing — Changes in BRCA2 and BRCA1, ATM, and the mismatch repair genes can be inherited and raise cancer risk in a family. Testing uses a blood or saliva sample rather than tumor tissue. It is generally offered for high-risk or metastatic disease, for intraductal carcinoma, or for a significant family history.
Mismatch repair and microsatellite instability — Tested on tumor tissue in advanced disease. A tumor with loss of mismatch repair may be eligible for immunotherapy.
Androgen receptor testing — Used in advanced prostate cancer that has stopped responding to hormone-blocking therapy. Changes in the androgen receptor help explain resistance and guide the choice of next treatment.

Because none of these is on the checklist, your report will not list them, and it may not mention that any were ordered. You can read more about each test in the Biomarkers and Genetic Testing section of this website.

What is the prognosis?

Prognosis is the expected course of a disease. For prostate cancer the outlook is better than for almost any other cancer. Across all stages combined, roughly 97 out of every 100 men diagnosed with prostate cancer are alive five years later.

When the cancer is confined to the prostate or has reached only nearby tissue, survival at five years is close to 100 percent. Most of these men die of something else entirely. When the cancer has spread to distant sites such as bone, five-year survival is closer to 37 out of 100, and that figure has been improving as new treatments arrive.

These figures describe large groups of men and cannot predict what will happen to any one person. The range of behavior within prostate cancer is unusually wide, and the findings on your report are what place you within it.

Grade Group — The strongest predictor on the report. Grade Group 1 cancers rarely spread, and Grade Group 5 cancers call for the most intensive treatment.
Amount of cancer — The number of positive cores, and how much of each core is involved.
Cribriform glands and intraductal carcinoma — Each raises risk beyond what the Grade Group alone indicates.
Extension beyond the gland — Periprostatic fat or seminal vesicle involvement moves the cancer into a higher stage and a higher risk group.
Perineural and vascular invasion — Each is associated with a higher risk of recurrence, though neither changes the grade or the stage.
PSA level — Measured in blood rather than reported by the pathologist, and combined with grade and stage to set your risk group.

What happens after this diagnosis?

The pathology report from a prostate biopsy is the document your treatment team uses to decide whether the cancer needs treatment now, and if so, which kind. A urologist usually coordinates care, often together with a radiation oncologist and a medical oncologist.

The findings on your report shape several decisions.

Active surveillance — Monitoring the cancer with regular PSA tests, examinations, MRI, and repeat biopsies, and treating only if it progresses. It is the usual approach for most men with Grade Group 1 disease and for selected men with favorable Grade Group 2 disease.
Surgery — Removal of the prostate, called radical prostatectomy. The pathology report from that operation gives the definitive grade and stage, which sometimes differ from the biopsy.
Radiation therapy — Delivered from outside the body, or by placing radioactive seeds in the gland. It is sometimes combined with hormone-blocking therapy.
Hormone-blocking therapy — Used with radiation in intermediate-risk and high-risk disease, and as a main treatment when the cancer has spread.
Further imaging — Bone scan, CT, or PSMA PET, considered on the basis of your grade and your PSA.
Genetic assessment — Considered on the basis of the grade, the presence of intraductal carcinoma, and your family history.

If any part of your report is unclear, your treating physician can request the full report from the laboratory and go through it with you. A second opinion on the pathology can also be arranged. Second review of prostate biopsies is common, and many centers treat it as standard before starting active surveillance.

Questions to ask your doctor

What is my Grade Group, and what Gleason score does it correspond to?
Is my Gleason score 3+4 or 4+3, and what difference does that make for me?
If my score is 7, what percentage of the cancer is pattern 4?
How many cores were taken, and how many contained cancer?
What was the greatest percentage of any single core involved by cancer?
Which measurement technique was used for that percentage?
Were cribriform glands found in my biopsy?
Was intraductal carcinoma found, and was it incorporated into my grade?
Which parts of my prostate were involved, and was cancer found on both sides?
Was perineural invasion found, and does it change anything in my case?
Does my report mention periprostatic fat or seminal vesicle invasion?
What risk group am I in once my PSA and clinical stage are taken into account?
Am I a candidate for active surveillance, and what would that involve?
Should I be referred for genetic testing based on my diagnosis and family history?