The official medical terminology used by doctors for Azure is “High-Risk.” Criteria for a man to be in Azure are: 

  1. No previous treatment with surgery or radiation.
  2. Bone scans without metastasis. 
  3. One or more of the following three risk factors:
    • PSA above 20 and less than 100, or
    • Gleason score above 7, or
    • A clinical stage of the prostate tumor that is felt by digital rectal exam extending across the midline of the gland i.e., stage T2b (Chapter 1).
  4.  Any cancer detected on a scan outside the prostate including the pelvic lymph nodes, but no cancer that has spread further beyond the pelvic lymph nodes.  

Azure is divided into three subcategories—Low, Basic, and High. Low-Azure is when PSA is under 10 and only small amounts of Gleason grade 8 tumor are present in one or two biopsy cores. Men with Low-Azure need to be evaluated with a multiparametric MRI (MP-MRI) to confirm that the tumor is relatively small and without any evidence for extracapsular extension or seminal vesicle invasion. Treatment for Low-Azure is the same as treatment for High-Teal. Men with Low-Azure should review the Teal section of the book (Section III starting with Chapter 15).

High-Azure is indicated by a Gleason score of 9 or 10 and/or a clinical stage of T3 or more (Chapter 1). High-Azure is also signaled by a PSA over 40 or when the cancer invades the seminal vesicles, the bladder, the rectum or the pelvic lymph nodes. Basic-Azure is defined as neither Low nor High (see Appendices I and II for further explanation of subtypes). 

Understanding the Importance of Microscopic Metastasis

If micro metastases are present and untreated, cancer recurrence is almost inevitable. When there is a significant likelihood of microscopic metastases, as is certainly the case with High-Azure, systemic hormonal therapy with testosterone inactivating pharmaceuticals (TIP) improves the chance for cure. One question frequently raised by patients relates to the performance of surgery to remove potentially cancerous pelvic lymph nodes with the goal of improving cure rates. While surgical removal of the pelvic lymph nodes may be useful for detecting microscopic metastases, surgical removal is not an effective method for improving cure rates. Surgeons simply can’t remove all the nodes. Therefore, other types of therapy are much more effective. Treatment protocols for High-Azure that fail to incorporate a strategy for treating potential microscopic metastases are associated with higher rates of cancer recurrence. 

Throughout this section of the book and the next section on Indigo, we will be continually revisiting the question of how to deal with potential microscopic metastases. Specifically, we will discuss all the different treatment modalities—TIP, radiation to pelvic lymph nodes, or chemotherapy—and when to use them. The goal is preemptive eradication of microscopic disease at an early stage, at a point when the disease is more likely to be curable. In the following chapter, we will introduce the varied ways TIP can be utilized, depending on the Stage of Blue and the circumstances of each individual patient.   


Mark Scholz, MD is the executive director of the Prostate Cancer Research Institute. He is also the medical director of Prostate Oncology Specialists Inc. He received his medical degree from Creighton University in Omaha, NE. Dr. Scholz completed his Internal Medicine internship and Medical Oncology fellowship at University of Southern California Medical Center. He is co-author of Invasion of the Prostate Snatchers.  He has authored over 20 scientific publications related to the treatment of prostate cancer.