Prostate Cancer: Prostate Nomograms: FAQs

1. What tool should I use? What does each tool predict?

Which tool you use depends on where you are in the stage of your disease and what treatment you have already had. The four nomograms are:

• Pre-Treatment

  This nomogram can be used to predict probability of survival prior to a primary treatment (radical prostatectomy, brachytherapy, or external beam radiation therapy).

• Post-Radical Prostatectomy Nomogram

  This nomogram can be used to predict a patient’s probability of survival after a radical prostatectomy — when the radical prostatectomy is the patient’s sole primary treatment.

• Salvage Radiation Therapy Nomogram

  This tool is for men who have experienced a recurrence of their prostate cancer after receiving a radical prostatectomy. It predicts treatment success for salvage radiation therapy.

• Hormone Refractory Nomogram

  This is for patients who are considering receiving hormone refractory treatment. It can be used by people who have been treated with prostatectomy or radiation therapy as a primary treatment. It predicts survival probability.

The three additional tools are:

• PSA Doubling Time

  This tool tracks PSA doubling time and can be used to predict the probability and time to the development of metastatic disease.

• Life Expectancy

  Using inputs of current age and racial category, this tool calculates average life expectancy, which can then be used for comparison when considering the survival probabilities of the various treatment options.

• Volume

  This tool calculates prostate tumor volume.

2. I’m a patient. Can I use the nomogram on my own?

We recommend that patients use this tool in consultation with their doctor before making any treatment decisions.

3. What is PFP (progression-free probability)?

It is the probability of avoiding any form of disease progression.

4. Why shouldn’t the patient simply pick the prostate cancer treatment with the highest predicted progression-free probability (PFP)?

There are several reasons:

• A rising PSA — one of the factors that these models predict — is not the most important endpoint for decision-making purposes. A rising PSA after treatment has no symptoms until the disease progresses, which is generally many years later. What we would like to be able to predict is symptoms of disease progression, which is considerably more difficult to predict. In other words, a rising PSA is not the most important endpoint for decision making purposes.
• Treatment complications are different for each patient. The patient needs to discuss potential complications with his doctor.
• Disease progression following each of the treatments may have differing prognoses. This means that subsequent progression for the patient who has a rising PSA following surgery may be more or less rapid than the progression for the patient with a rising PSA following a form of radiation. In other words, the endpoint being predicted may mean different things across treatments. We are not sure.
• Experts from different disciplines (urology, radiation oncology, etc.) may not assign the patient the same stage (an assigned value indicating the extent of the tumor in the prostate and whether cancer cells have spread to surrounding tissues or other parts of the body). For example, the stage a surgeon assigns a patient may be different from the stage a radiation oncologist assigns that same patient.
• These tools were based on and validated by patients who were treated primarily at academic centers of excellence. It is unclear to what degree the results generalize to patients treated outside those settings because those data are difficult to obtain. This is important to note because some studies suggest that more experienced surgeons have better outcomes than do less experienced surgeons. Specific to these nomograms, our data suggests that outcomes following brachytherapy may be highly variable across centers. The patient should ask his physician whether he or she believes these predictions are representative. The individual tools included in this nomogram predict variously to one, two, five, seven, eight, and ten years after treatment. A longer time horizon is needed for definitive treatment comparison.

These nomograms cannot definitively answer the question of which treatment is most appropriate for an individual patient. These tools simply provide information useful for the decision-making process, which should be carried out in consultation with a physician.

5. I have a very low probability of having organ-confined prostate cancer. Does this mean surgery (or any other treatment) cannot cure me?

Not necessarily. In fact, about 50 percent of patients who do not have organ-confined cancer have long-term freedom from recurrence following surgery. The probability of having organ-confined prostate cancer is not equal to the probability that surgery will provide long-term freedom from recurrence because the cancer does not have to be organ confined to be successfully treated with surgery.

6. What do the probabilities of organ confined disease, extra capsular penetration, seminal vesicle involvement, and lymph node involvement mean?

After surgery, it is common to assign a patient into one of four groups (known as pathologic stages) depending on the extent of disease. These groups are (1) disease confined to the prostate, without spread into the seminal vesicles or the lymph nodes; (2) disease that is evident outside the prostatic capsule, but has not spread into the seminal vesicles or lymph nodes; (3) disease that has spread into the seminal vesicles but not the spread into the pelvic lymph nodes; or (4) disease that has spread into the lymph nodes. The probabilities from our prediction tool are predictions of how likely it is that the patient would be placed into each of these categories of pathologic stage. These are predictions based on clinical stage, pretreatment PSA, and biopsy Gleason grade. Note that additional diagnostics such as imaging (CT, MRI, etc.) might affect these predictions. For example, the patient who has had an MRI that suggests organ-confined disease might have a higher probability of actually having organ-confined disease than would be predicted from our tool, which does not directly incorporate imaging.

7. In the Pre-Treatment model of the nomogram what is the difference between the Basic and Enhanced options?

The enhanced model allows a user to enter more clinical data, including prostate side-specific details, which will produce more specific probability results.

8. In both the Pre-Treatment and Post-Radical Prostatectomy tools, why are the results divided between a Current Model and an Historical Model?

The original version of the prostate nomogram, released in 2003, based its calculations on data from earlier studies. New studies have been completed, the data from which has been added to the new and enhanced nomogram. The Historical Model is included in this new version of the nomogram because its results are still being used by researchers and some physicians.

9. What is the 1992 Clinical Tumor Staging System?

The global standard in prostate cancer staging is the TNM classification of malignant tumors. Doctors throughout the world use the tumor, lymph node, and metastasis (TNM) system for staging most cancers. The following is the fourth edition of the American Joint Committee on Cancer Staging Systems for prostate cancer. These stages are listed on the pathology report.

• TX: cannot evaluate the primary tumor
• T0: no evidence of tumor
• T1: tumor present, but not detectable clinically or with imaging
  • T1a: tumor was incidentally found in less than 5 percent of prostate tissue resected (for other reasons)
  • T1b: tumor was incidentally found in greater than 5 percent of prostate tissue resected
  • T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA
• T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate
  • T2a: the tumor is in half or less than half of one of the prostate gland’s two lobes
  • T2b: the tumor is in more than half of one lobe, but not both
  • T2c: the tumor is in both lobes
• T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2)
  • T3a: the tumor has spread through the capsule on one or both sides
  • T3b: the tumor has invaded one or both seminal vesicles
• T4: the tumor has invaded other nearby structures

10. What is the 1997 Clinical Tumor Staging System?

The global standard in prostate cancer staging is the TNM classification of malignant tumors. Doctors throughout the world use the tumor, lymph node, and metastasis (TNM) system for staging most cancers. The following is the fifth edition of the American Joint Committee on Cancer Staging Systems for prostate cancer. These stages are listed on the pathology report.

• TX: cannot evaluate the primary tumor
• T0: no evidence of tumor
• T1: tumor present, but not detectable clinically or with imaging
  • T1a: tumor was incidentally found in less than 5 percent of prostate tissue resected (for other reasons)
  • T1b: tumor was incidentally found in greater than 5 percent of prostate tissue resected
  • T1c: tumor was found in a needle biopsy performed due to an elevated serum PSA
• T2: the tumor can be felt (palpated) on examination, but has not spread outside the prostate
  • T2a: the tumor is in half or less than half of one of the prostate gland’s two lobes, or the tumor is in more than half of one lobe, but not both
  • T2b: the tumor is in both lobes
• T3: the tumor has spread through the prostatic capsule (if it is only part-way through, it is still T2)
  • T3a: the tumor has spread through the capsule on one or both sides
  • T3b: the tumor has invaded one or both seminal vesicles
• T4: the tumor has invaded other nearby structures

11. What is the Gleason Grade?

Physicians characterize the aggressiveness of prostate cancer using the Gleason grading system, which provides an estimate of the cancer’s potential to grow and spread to other parts of the body. The pathologist determines the Gleason grade based on how closely the cells of the gland resemble those of a normal prostate. Once the prostate is removed during surgery, a pathologist examining the prostate assigns a grade to the most common tumor, known as the primary Gleason grade, and a second grade to the next most common tumor, known as the secondary Gleason grade. The two grades are added together to get a Gleason score, also known as the Gleason sum.

12. What is PSA Doubling Time?

PSA Doubling Time can be an indicator of biochemical and clinical progression. This tool predicts the changes in PSA levels over time.

13. What should I do with the results produced by the nomogram?

These nomograms cannot definitively answer the question of which treatment is most appropriate for an individual patient. These tools simply provide information useful for the decision-making process, which should be carried out in consultation with a physician.

14. What if the nomogram produces no results?

Confirm that all of the clinical data you have entered falls within the acceptable range for each data field. To do so, roll your cursor over the blue ? circle located to the right of each field.

Note, however, that certain combinations of correctly entered clinical data will produce results for some prediction fields but not others.

15. I don’t have all the information necessary to make the nomogram work. Where can I find those missing inputs?

We encourage patients to use the prediction tools with their doctors. If you do not have all the inputs necessary to make the nomogram work, print the worksheet for the nomogram tool that you are using and bring it with you to your next doctor’s appointment. Oftentimes, the information necessary is on the pathology report, and your doctor should have a copy of that in your file.