For decades physicians have attempted to accurately predict post-treatment outcomes before performing prostate cancer interventions. Use of basic clinical factors, such as clinical T-stage, biopsy Gleason sum, and pretreatment prostate-specific antigen (PSA), has allowed some level of prediction of pathologic (e.g., pathologic T-stage and Gleason sum, nodal involvement) and clinical outcomes (e.g., biochemical failure, clinical failure). Although easy to use, these basic tables and risk stratification schema provide a broad range of potential outcomes. This may not be surprising given that the number of factors used in these predictive models is relatively limited. The rapid growth of retrospective research in prostate cancer has yielded an abundance of additional potential prognostic factors that may influence outcomes of interest; however, incorporating and understanding the significance of these ever-expanding factors is difficult for even the most experienced physicians.
Nomograms incorporate these factors (including treatment-specific) and assign them relative weights to provide a probability of the outcome of interest on a graphical scale. They have the advantage of distilling large numbers of data into a manageable format and provide the probability of outcomes on a continuous scale rather than in categoric groups. Because they require a computation to generate a probability, they are not amenable to memorization, which decreases their ease of use. However, the ubiquitous availability of portable computing and Internet access is making this less of an issue.
Clinicians and patients should still exercise due diligence when interpreting the results of these nomograms. Although the generation of a specific percent chance of an outcome is seductive, these numbers still have associated confidence intervals and the models are largely derived from retrospective data, which have inherent drawbacks. These prediction tools are useful in assisting physicians and patients but should not serve as a stand-alone substitute for clinical decision-making.
Partin AW, Kattan MW, Subong EN et al.. Combination of prostate-specific antigen, clinical stage, and Gleason score to predict pathological stage of localized prostate cancer. A multi-institutional update. JAMA 1997;277:1445–1451.
D'Amico AV, Whittington R, Malkowicz SB et al.. A multivariable analysis of clinical factors predicting for pathological features associated with local failure after radical prostatectomy for prostate cancer. Int J Radiat Oncol Biol Phys 1994;30:293–302.
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;280:969–974.
Potters L, Cha C, Oshinsky G et al.. Risk profiles to predict PSA relapse-free survival for patients undergoing permanent prostate brachytherapy. Cancer J Sci Am 1999;5:301–306.
Zelefsky MJ, Wallner KE, Ling CC et al.. Comparison of the 5-year outcome and morbidity of three-dimensional conformal radiotherapy versus transperineal permanent iodine-125 implantation for early-stage prostatic cancer. J Clin Oncol 1999;17:517–522.
D'Amico AV, Whittington R, Malkowicz SB et al.. Combination of the preoperative PSA level, biopsy gleason score, percentage of positive biopsies, and MRI T-stage to predict early PSA failure in men with clinically localized prostate cancer. Urology 2000;55:572–577.
D'Amico AV, Cote K, Loffredo M et al.. Pretreatment predictors of time to cancer specific death after prostate specific antigen failure. J Urol 2003;169:1320–1324.
D'Amico AV, Cote K, Loffredo M et al.. Determinants of prostate cancer-specific survival after radiation therapy for patients with clinically localized prostate cancer. J Clin Oncol 2002;20:4567–4573.
D'Amico AV, Cote K, Loffredo M et al.. Determinants of prostate cancer specific survival following radiation therapy during the prostate specific antigen era. J Urol 2003;170(6 Pt 2):S42–46; discussion S46–47.
D'Amico AV, Keshaviah A, Manola J et al.. Clinical utility of the percentage of positive prostate biopsies in predicting prostate cancer-specific and overall survival after radiotherapy for patients with localized prostate cancer. Int J Radiat Oncol Biol Phys 2002;53:581–587.
- Search Google Scholar
- Export Citation
. D'Amico AV Keshaviah A Manola J Clinical utility of the percentage of positive prostate biopsies in predicting prostate cancer-specific and overall survival after radiotherapy for patients with localized prostate cancer. Int J Radiat Oncol Biol Phys 2002; 53: 581– 587.
D'Amico AV, Renshaw AA, Cote K et al.. Impact of the percentage of positive prostate cores on prostate cancer-specific mortality for patients with low or favorable intermediate-risk disease. J Clin Oncol 2004;22:3726–3732.
D'Amico AV, Whittington R, Malkowicz B et al.. Endorectal magnetic resonance imaging as a predictor of biochemical outcome after radical prostatectomy in men with clinically localized prostate cancer. J Urol 2000;164(3 Pt 1):759–763.
Greene KL, Meng MV, Elkin EP et al.. Validation of the Kattan preoperative nomogram for prostate cancer recurrence using a community based cohort: results from cancer of the prostate strategic urological research endeavor (capsure). J Urol 2004;171(6 Pt 1):2255–2259.
Makarov DV, Trock BJ, Humphreys EB et al.. Updated nomogram to predict pathologic stage of prostate cancer given prostate-specific antigen level, clinical stage, and biopsy Gleason score (Partin tables) based on cases from 2000 to 2005. Urology 2007;69:1095–1101.
Epstein JI, Carmichael MJ, Partin AW, Walsh PC. Small high grade adenocarcinoma of the prostate in radical prostatectomy specimens performed for nonpalpable disease: pathogenetic and clinical implications. J Urol 1994;151:1587–1592.
Kattan MW, Eastham JA, Wheeler TM et al.. Counseling men with prostate cancer: a nomogram for predicting the presence of small, moderately differentiated, confined tumors. J Urol 2003;170:1792–1797.
Steyerberg EW, Roobl MJ, Kattan MW et al.. Prediction of indolent prostate cancer: validation and updating of a prognostic nomogram. J Urol 2007;177:107–112.
Chun FK, Steuber T, Erbersdobler A et al.. Development and internal validation of a nomogram predicting the probability of prostate cancer Gleason sum upgrading between biopsy and radical prostatectomy pathology. Eur Urol 2006;49:820–826.
Chun FK, Briganti A, Shariat SF et al.. Significant upgrading affects one in three men diagnosed with prostate cancer-predictive nomogram and internal validation. BJU Int 2006;98:329–334.
Graefen M, Haese A, Pichlmeier U et al.. A validated strategy for side specific prediction of organ confined prostate cancer: a tool to select for nerve sparing radical prostatectomy. J Urol 2001;165:857–863.
Ohori M, Kattan MW, Koh H et al.. Predicting the presence and side of extracapsular extension: a nomogram for staging prostate cancer. J Urol 2004;171:1844–1849.
Steuber T, Graefen M, Haese A. Validation of a nomogram for prediction of side specific extracapsular extension at radical prostatectomy. J Urol 2006;175(3 pt 1):939–944.
Koh H, Kattan MW, Scardino PT et al.. A nomogram to predict seminal vesicle invasion by the extent and location of cancer in systematic biopsy results. J Urol 2003;170(4 Pt 1):1203–1208.
Cagiannos I, Karakiewicz P, Eastham JA et al.. A preoperative nomogram identifying decreased risk of positive pelvic lymph nodes in patients with prostate cancer. J Urol 2003;170:1798–1803.
Briganti A, Chun FK, Salonia A et al.. Validation of a nomogram predicting the probability of lymph node invasion among patients undergoing radical prostatectomy and an extended pelvic lymphadenectomy. Eur Urol 2006;49:1019–1026.
Briganti A, Chun FK, Salonia A et al.. A nomogram for staging of exclusive nonobturator lymph node metastases in men with localized prostate cancer. Eur Urol 2007;51:112–119.
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;90:766–771.
Kattan MW, Wheeler TM, Scardino PT. Postoperative nomogram for disease recurrence after radical prostatectomy for prostate cancer. J Clin Oncol 1999;17:1499–1507.
Graefen M, Karakiewicz PI, Cagiannos I et al.. Validation study of the accuracy of a postoperative nomogram for recurrence after radical prostatectomy for localized prostate cancer. J Clin Oncol 2002;20:951–956.
Bianco FJ Jr, Katan MW, Scardino PT et al.. Radical prostatectomy nomograms in black American men: accuracy and applicability. J Urol 2003;170:73–76.
Stephenson AJ, Scardino PT, Eastham JA et al.. Postoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy. J Clin Oncol 2005;23:7005–7012.
Stephenson AJ, Scarcino PT, Eastham JA et al.. Preoperative nomogram predicting the 10-year probability of prostate cancer recurrence after radical prostatectomy. J Natl Cancer Inst 2006;98:715–717.
Bianco FJ Jr, Kattan MW, Scardino PT et al.. Radical prostatectomy nomograms in black American men: accuracy and applicability. J Urol 2003;170:73–76.
Suardi N, Porter CR, Reuther AM et al.. A nomogram predicting long-term biochemical recurrence after radical prostatectomy. Cancer 2008;112:1254–1263.
Klein EA, Bianco FJ, Serio AM et al.. Surgeon experience is strongly associated with biochemical recurrence after radical prostatectomy for all preoperative risk categories. J Urol 2008;179:2212–2216.
Vickers AJ, Bianco FJ, Gonen M et al.. Effects of pathologic stage on the learning curve for radical prostatectomy: evidence that recurrence in organ-confined cancer is largely related to inadequate surgical technique. Eur Urol 2008;53:960–966.
Vickers AJ, Bianco FJ, Serio AM et al.. The surgical learning curve for prostate cancer control after radical prostatectomy. J Natl Cancer Inst 2007;99:1171–1177.
Kattan MW, Vickers AJ, Changhong Y et al.. Preoperative and postoperative nomograms incorporating surgeon experience for clinically localized prostate cancer. Cancer 2009;115:1005–1010.
Dotan ZA, Bianco JF Jr, Rabbani F et al.. Pattern of prostate-specific antigen (PSA) failure dictates the probability of a positive bone scan in patients with an increasing PSA after radical prostatectomy. J Clin Oncol 2005;23:1962–1968.
Slovin SF, Wilton AS, Heller G, Scher HI. Time to detectable metastatic disease in patients with rising prostate-specific antigen values following surgery or radiation therapy. Clin Cancer Res 2005;11(24 pt 1):8669–8673.
Stephenson AJ, Scardino PT, Kattan MW et al.. Predicting outcome of salvage radiation therapy for recurrent prostate cancer after radical prostatectomy. J Clin Oncol 2007;25:2035–2041.
Kattan MW, Zelefsky MJ, Kupelian PA et al.. Pretreatment nomogram for predicting the outcome of three-dimensional conformal radiotherapy in prostate cancer. J Clin Oncol 2000;18:3352–3359.
D'Amico AV, Chen MH, Renshaw AA et al.. Androgen suppression and radiation vs radiation alone for prostate cancer: a randomized trial. JAMA 2008;299:289–295.
Horwitz EM, Bae K, Hanks GE et al.. Ten-year follow-up of radiation therapy oncology group protocol 92-02: a phase III trial of the duration of elective androgen deprivation in locally advanced prostate cancer. J Clin Oncol 2008;26:2497–2504.
Horwitz EM, Winter K, Hanks GE et al.. Subset analysis of RTOG 85-31 and 86-10 indicates an advantage for long-term vs. short-term adjuvant hormones for patients with locally advanced nonmetastatic prostate cancer treated with radiation therapy. Int J Radiat Oncol Biol Phys 2001;49:947–956.
- Search Google Scholar
- Export Citation
. Horwitz EM Winter K Hanks GE Subset analysis of RTOG 85-31 and 86-10 indicates an advantage for long-term vs. short-term adjuvant hormones for patients with locally advanced nonmetastatic prostate cancer treated with radiation therapy. Int J Radiat Oncol Biol Phys 2001; 49: 947– 956.
Zelefsky MJ, Yamada Y, Fuks Z et al.. Long-term results of conformal radiotherapy for prostate cancer: impact of dose escalation on biochemical tumor control and distant metastases-free survival outcomes. Int J Radiat Oncol Biol Phys 2008;71:1028–1033.
Zelefesky MJ, Kattan MW, Fearn P et al.. Pretreatment nomogram predicting ten-year biochemical outcome of three-dimensional conformal radiotherapy and intensity-modulated radiotherapy for prostate cancer. Urology 2007;70:283–287.
Kattan MW, Potters L, Blasko JC et al.. Pretreatment nomogram for predicting freedom from recurrence after permanent prostate brachytherapy in prostate cancer. Urology 2001;58:393–399.
Frank SJ, Levy LB, Kuban DA et al.. Prostogram predicted brachytherapy outcomes are not universally accurate: an analysis based on the M. D. Anderson Cancer Center experience with (125)iodine brachytherapy. J Urol 2009;181:1658–1663; discussion 1663–1654.
Potters L, Roach M III, Davis BJ et al.. Postoperative nomogram predicting the 9-year probability of prostate cancer recurrence after permanent prostate brachytherapy using radiation dose as a prognostic variable. Int J Radiat Oncol Biol Phys 2009; in press.
Kattan MW, Zelefsky MJ, Kupelian PA et al.. Pretreatment nomogram that predicts 5-year probability of metastasis following three-dimensional conformal radiation therapy for localized prostate cancer. J Clin Oncol 2003;21:4568–4571.