Elsevier

Urology

Volume 62, Supplement, 29 December 2003, Pages 9-18
Urology

Use of nomograms to predict the risk of disease recurrence after definitive local therapy for prostate cancer

https://doi.org/10.1016/j.urology.2003.09.029Get rights and content

Abstract

The generally indolent nature of prostate cancer, as well as the impact that treatment can have on quality of life (QOL) and cancer control, makes the decision analysis difficult for patients facing the task of selecting a treatment for clinically localized disease. Instruments to aid patients and their physicians in this decision analysis are needed. Nomograms are instruments that predict outcomes using specific clinical parameters. Nomograms use algorithms that incorporate several variables to calculate the predicted probability that a patient will achieve a particular clinical end point. Nomograms tend to outperform both clinical experts and predictive models using methods of risk grouping. We briefly outline the uses and limitations of nomograms, principles of nomogram construction, and the available models for predicting the progression-free probability after local definitive therapy with radical prostatectomy, external-beam radiotherapy, or brachytherapy. There is a need for additional nomograms that predict outcomes after salvage therapy, as well other clinical end points, including QOL-adjusted survival.

Section snippets

The utility of nomograms

Prostate cancer can be seen as a chain of interconnected disease states ranging from diagnosis to death; nomograms can provide useful predictions for each disease state. At diagnosis, a patient faces the daunting task of selecting a treatment that offers the most promising outlook for cure, as well as for QOL. At this stage, nomograms can predict cancer control based on a patient's clinical parameters and the treatment selected. Similarly, for patients who have undergone local definitive

General principles

Several considerations apply when designing nomograms. A nomogram should accurately predict which patients will and will not reach the end point (discrimination), generate predictions that closely approximate actual outcomes (calibration), and perform consistently when applied to different data sets (validation). They should also be based on a sufficient number of cases; specifically, they must incorporate a large enough proportion of cases that reach the end point of interest. Nomograms should

Development considerations

The Memorial Sloan-Kettering Cancer Center (MSKCC) nomograms developed by Kattan et al.19 are based on Cox proportional hazards regression analysis modified by restricted cubic splines.19, 28, 34, 35, 36 Unmodified Cox models require variables to assume linear relations, which is not ideal because it assumes that incremental changes represent the same significance across the spectrum of values. For example, an increase in PSA level from 2 ng/mL to 4 ng/mL would represent the same significance

Nomograms available for patients with prostate cancer

Many nomograms exist for prostate cancer.24 This discussion, however, will be restricted to 4 contemporary models that predict the continuous risk of disease progression after local definitive therapy with RRP,34, 35 EBRT,19 or TPIPB.36 Each of the pretreatment models predicts the 5-year probability of remaining free from disease progression (ie, the progression-free probability), based on PSA relapse after definitive therapy. The postoperative model predicts the 7-year progression-free

Limitations of nomograms

Although clinically useful for counseling patients, nomograms are far from perfect and cannot be applied to all men with prostate cancer. In general, nomograms are constructed19, 20, 21, 34, 35, 36, 44, 46 and validated29, 41, 42 using patients treated at academic centers, whose outcomes may differ considerably from outcomes of patients treated at community health centers, because the quality and availability of treatments can vary with the location and experience level of the treating

Conclusion

Nomograms have proved useful as adjunctive tools for counseling patients with prostate cancer. Although current nomograms are limited in their application and accuracy, efforts are continuously under way to improve them and to develop novel instruments for other end points. The ultimate objective is to construct a suite of nomograms that can predict cancer control and survival, as well as quality-adjusted survival, to help guide the selection of treatments at all stages of prostate cancer. The

References (66)

  • M.W. Kattan et al.

    A postoperative prognostic nomogram for renal cell carcinoma

    J Urol

    (2001)
  • P.L. Ross et al.

    A catalog of prostate cancer nomograms

    J Urol

    (2001)
  • M.W. Kattan et al.

    Pretreatment nomogram for predicting freedom from recurrence after permanent prostate brachytherapy in prostate cancer

    Urology

    (2001)
  • T.Y. Chan et al.

    Prognostic significance of Gleason score 3+4 versus Gleason score 4+3 tumor at radical prostatectomy

    Urology

    (2000)
  • M. Graefen et al.

    A validation of two preoperative nomograms predicting recurrence following radical prostatectomy in a cohort of European men

    Urol Oncol

    (2002)
  • A.W. Partin et al.

    The use of prostate specific antigen, clinical stage and Gleason score to predict pathological stage in men with localized prostate cancer

    J Urol

    (1993)
  • G.W. Hull et al.

    Cancer control with radical prostatectomy alone in 1,000 consecutive patients

    J Urol

    (2002)
  • A.W. Partin et al.

    Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millennium

    Urology

    (2001)
  • T.M. Wheeler et al.

    Clinical and pathologic significance of the level and extent of capsular invasion in clinical stage T1-2 prostate cancer

    Hum Pathol

    (1998)
  • M.J. Zelefsky et al.

    Five-year biochemical outcome and toxicity with transperineal CT-planned permanent I-125 prostate implantation for patients with localized prostate cancer

    Int J Radiat Oncol Biol Phys

    (2000)
  • S.H. Stokes et al.

    Transperineal ultrasound-guided radioactive seed implantation for organ-confined carcinoma of the prostate

    Int J Radiat Oncol Biol Phys

    (1997)
  • F.A. Critz et al.

    Post-treatment PSA < or = 0.2 ng/mL defines disease freedom after radiotherapy for prostate cancer using modern techniques

    Urology

    (1999)
  • G.E. Hanks et al.

    Conformal external beam treatment of prostate cancer

    Urology

    (1997)
  • C.L. Amling et al.

    Defining prostate specific antigen progression after radical prostatectomywhat is the most appropriate cut point?

    J Urol

    (2001)
  • H. Zincke et al.

    Long term (15 years) results after radical prostatectomy for clinically localized (stage T2c or lower) prostate cancer

    J Urol

    (1994)
  • W.J. Catalona et al.

    Five-year tumor recurrence rates after anatomical radical retropubic prostatectomy for prostate cancer

    J Urol

    (1994)
  • A.V. D'Amico et al.

    Pretreatment predictors of time to cancer specific death after prostate specific antigen failure

    J Urol

    (2003)
  • A. Jemal et al.

    Cancer statistics, 2003

    CA Cancer J Clin

    (2003)
  • G.S. Gerber et al.

    Results of radical prostatectomy in men with clinically localized prostate cancer

    JAMA

    (1996)
  • H. Ragde et al.

    Interstitial iodine-125 radiation without adjuvant therapy in the treatment of clinically localized prostate carcinoma

    Cancer

    (1997)
  • G.W. Chodak et al.

    Results of conservative management of clinically localized prostate cancer

    N Engl J Med

    (1994)
  • P.C. Albertsen et al.

    Long-term survival among men with conservatively treated localized prostate cancer

    JAMA

    (1995)
  • M.E. Cowen et al.

    The danger of applying group-level utilities in decision analyses of the treatment of localized prostate cancer in individual patients

    Med Decis Making

    (1998)
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