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Prostate Cancer Prognostic Nomograms

Prognostic Nomograms and Algorithms

Prostate cancer nomograms and tables are tools which may be used to asses risk at different levels. They may use preoperative clinical data to estimate the risk of extraprostatic extension or recurrence. Alternatively, they may assess the risk of tumor recurrence based on postoperative pathological variables.

Predictive Tables

Predictive tables categorize patients based on risk according to preoperative variables such as pretreatment PSA, Gleason score, clinical stage, and biopsy density. They provide a range of risk for patients within that group, and not a specific number of recurrence risk for the individual patient. The most recent version of the Partin Tables, released in 2001, include over 5000 patients who underwent radical prostatectomy at Johns Hopkins by a single surgeon. They provide information regarding the risk of extraprostatic extension, seminal vesicle involvement, or lymph node metastasis. Although its data are biased since they are based on patients with early stage prostate cancer selected by a single surgeon, these were validated at the Mayo Clinic with a cohort of over 2400 patients. Nevertheless, they serve as a useful tool to estimate local advancement of tumors and to guide surgical management. These are available at http://urology.jhu.edu/prostate/partintables.php

Center for Prostate Disease Research Tables. Similar to the Partin Tables, the CPDR Tables (available on PDF format on www.cpdr.com) provide information on pathologic stage based on preoperative clinical parameters and not a tumor progression risk assessment. They are based on a more racially diverse population of patients who underwent surgery at multiple institutions and take into account the density of positive biopsies.

D'Amico Tables. Provide prognostic information on biochemical recurrence for patients treated with radical prostatectomy and radiation therapy. Provides additional information in patients with a high density of positive biopsies when endorectal MRI was used. Its main criticism is the use of a definition of three consecutive rises in PSA for biochemical failure in surgically treated patients. Furthermore, Gleason 7 patients were not subdivided according to their primary Gleason grade (3+4 vs. 4+3) and 2-year PSA recurrence was used as a surrogate for long term outcome.

Other validated classification systems have been developed since the D'Amico.  The Cancer of the Prostate Risk Assessment (CAPRA) score is a system being used today.  

Nomograms

Nomograms are instruments which predict outcome on individual patients. The data entered into the equation may include preoperative clinical variables or pathological characteristics after treatment (in the case of patients treated with radical prostatectomy). Aside from being accurate, the ideal nomogram should not be culturally biased, pathologist or surgeon dependent, and should apply to the patient in the community and not the well selected patient commonly seen in tertiary care institutions.

Kattan Preoperative Nomogram. This nomogram provides an assessment of risk of recurrence based on clinical variables such as serum PSA, clinical stage, and biopsy Gleason grade. Although some have criticized this nomogram for using a definition of > 0.4 ng/ml for PSA recurrence, this nomogram has been validated with a cohort of over 6700 patients from different institutions and its results were consistently accurate independent of the definition of failure used by the institution. A PDA format of this nomogram is available at http://www.mskcc.org/mskcc/html/10088.cfm

Kattan Postoperative Nomogram. Provides more accurate (area under the curve: 0.89) prognostic information compared with the preoperative nomogram (AUC: 0.74) because of the additional pathologic information obtained from the prostatectomy specimen. Although the data stem from the experience of a single surgeon, the nomogram has been validated on a multi-institutional setting. A PDA format of this nomogram is available at http://www.mskcc.org/mskcc/html/10088.cfm.

Kattan Prognostic Nomogram for Metastatic Prostate Cancer. Provides median survival and 1-year and 2-year survival estimates for patients with castrate androgen levels and progressive metastatic disease. The nomogram is based on patient age, Karnofsky performance status, serum hemoglobin, PSA, LDH, alkaline phosphatase, and albumin. (Smaletz et al, JCO 20(19):3972, 2002).

CaPSURE/CPDR Recurrence Equation. Biostatistical model produced between the Center for Prostate Disease Research and CaPSURE (Cancer of the Prostate Strategic Urologic Research Endeavor), a longitudinal observational study of prostate cancer patients nationwide. The equation offers an assessment of recurrence risk based on pretreatment PSA, highest Gleason sum on prostatectomy specimen, prostatectomy organ confinement status, and ethnicity (Recurrence risk = exp[0.54 x race) + (0.05 x PSA) + (0.23 x postop Gleason) + (0.69 x pathologic stage)]. These data stratified patients into 4 risk groups: very low- (4.7 or less), low- (4.7 to 7.1), high-(7.1 to 16.7), and very high- (greater than 16.7). Patients at risk had 7-year disease-free survival rates of 85.4%, 66.0%, 50.6% and 21.3%, respectively. Refer to Moul et al, J Urol 2001 Oct;166(4):1322-7 for details.

References

  • Blute ML, Bergstralh EJ, Partin AW, Walsh PC, Kattan MW, Scardino PT, Montie JE, Pearson JD, Slezak JM, Zincke H. Validation of Partin tables for predicting pathological stage of clinically localized prostate cancer. J Urol. 2000 Nov;164(5):1591-5
  • Cooperberg et al, 2006. Cooperberg MR, Freedland SJ, Pasta DJ, et al: Multiinstitutional validation of the UCSF cancer of the prostate risk assessment for prediction of recurrence after radical prostatectomy. Cancer  2006; 107(10):2384-2391.
  • Cooperberg et al, 2005. Cooperberg MR, Pasta DJ, Elkin EP, et al: The University of California, San Francisco Cancer of the Prostate Risk Assessment score: a straightforward and reliable preoperative predictor of disease recurrence after radical prostatectomy. J Urol  2005; 173(6):1938-1942.
  • Cooperberg et al, 2002. Cooperberg MR, Lubeck DP, Grossfeld GD, et al: Contemporary trends in imaging test utilization for prostate cancer staging: data from the cancer of the prostate strategic urologic research endeavor. J Urol  2002; 168(2):491-495.
  • D’Amico et al, 1998. D’Amico AV, Whittington R, Malkowicz SB, et al: Biochemical outcome after radical prostatectomy, external beam radiation therapy, or interstitial radiation therapy for clinically localized prostate cancer. JAMA  1998; 280(11):969-974.
  • D’Amico et al, 2001. D’Amico AV, Whittington R, Malkowicz SB, et al: Predicting prostate specific antigen outcome preoperatively in the prostate specific antigen era. J Urol  2001; 166(6):2185-2188.
  • D'amico AV, Tempany CM, Schultz D, Cormack RA, Hurwitz M, Beard C, Albert M, Kooy H, Jolesz F, Richie JP. Comparing PSA outcome after radical prostatectomy or magnetic resonance imaging-guided partial prostatic irradiation in select patients with clinically localized adenocarcinoma of the prostate. Urology. 2003 Dec;62(6):1063-7.
  • Epstein et al, 1994. Epstein JI, Walsh PC, Carmichael M, et al: Pathologic and clinical findings to predict tumor extent of nonpalpable (stage T1c) prostate cancer. JAMA  1994; 271(5):368-374.
  • Graefen M, Karakiewicz PI, Cagiannos I, Klein E, Kupelian PA, Quinn DI, Henshall SM, Grygiel JJ, Sutherland RL, Stricker PD, de Kernion J, Cangiano T, Schroder FH, Wildhagen MF, Scardino PT, Kattan MW. Validation study of the accuracy of a postoperative nomogram for recurrence after radical prostatectomy for localized prostate cancer. J Clin Oncol. 2002 Feb 15;20(4):951-6.
  • Kattan et al, 1998. Kattan MW, Eastham JA, Stapleton AM, et al: A preoperative nomogram for disease recurrence following radical prostatectomy for prostate cancer. J Natl Cancer Inst  1998; 90(10):766-771.
  • May et al, 2007. May M, Knoll N, Siegsmund M, et al: Validity of the CAPRA score to predict biochemical recurrence-free survival after radical prostatectomy. Results from a European multicenter survey of 1,296 patients. J Urol  2007; 178(5):1957-1962.
  • Moul JW. Outcome research: prostate cancer databases. Urol Oncol. 2002 Jan-Feb;7(1):39-42.
  • Moul JW, Connelly RR, Lubeck DP, Bauer JJ, Sun L, Flanders SC, Grossfeld GD, Carroll PR. Predicting risk of prostate specific antigen recurrence after radical prostatectomy with the Center for Prostate Disease Research and Cancer of the Prostate Strategic Urologic Research Endeavor databases. J Urol. 2001 Oct;166(4):1322-7.
  • Moul JW, Connelly RR, Lubeck DP, Bauer JJ, Sun L, Flanders SC, Grossfeld GD, Carroll PR. Predicting risk of prostate specific antigen recurrence after radical prostatectomy with the Center for Prostate Disease Research and Cancer of the Prostate Strategic Urologic Research Endeavor databases. J Urol. 2001 Oct;166(4):1322-7.
  • Partin AW, Mangold LA, Lamm DM, Walsh PC, Epstein JI, Pearson JD. Contemporary update of prostate cancer staging nomograms (Partin Tables) for the new millennium Urology. 2001 Dec;58(6):843-8.
  • Smaletz O, Scher HI, Small EJ, Verbel DA, McMillan A, Regan K, Kelly WK, Kattan MW. Nomogram for overall survival of patients with progressive metastatic prostate cancer after castration. J Clin Oncol. 2002 Oct 1;20(19):3972-82