Clinical States Treatment Model

Prostate Nomogram Our Prostate Nomogram helps physicians and patients decide which treatment will result in the greatest benefit more

Our prostate cancer specialists are expert at predicting how likely each patient's disease is to progress -- no matter what the current status of his disease. An important tool in this method of risk stratification is a nomogram. This is a mathematical algorithm developed by researchers at Memorial Sloan-Kettering that uses the best predictive factors known today -- the stage of the cancer, PSA level, biopsy pathology, and treatment history -- to help physicians assess the probable course of a patient's disease and determine the treatment most likely to be effective for him.

Resetting the Clock: The Five Clinical States of Prostate Cancer

Prostate cancer affects many men as they age, and men often live with the disease for years. In each man with prostate cancer the disease will manifest itself in different ways . For some the disease does not pose a threat to their health, whereas for others it is, or it becomes, a primary threat. In recognition of the broad spectrum of ways in which the disease evolves, our prostate team has developed a model of prostate cancer at several different disease states.

Using this dynamic new model clinicians here define treatment goals for each patient when he is first diagnosed, and they redefine those goals as the disease unfolds. Our treatment decisions are guided by the needs of each patient at each different phase of the disease. Memorial Sloan-Kettering's model places men into one of five categories (below), called clinical states. Men remain in a particular state as long as their disease does not progress or recur.

Treatment for the Five Clinical States of Prostate Cancer are as follows:

1. No Cancer Diagnosis: Prevention & High-Risk Screening

   Some men may not have a diagnosis of prostate cancer, but because they have an elevated or rising PSA or a family history of the disease, they are at higher risk of developing the disease. Men in this state are closely watched and undergo regular digital rectal examinations and PSA testing.

   Memorial Sloan-Kettering is one of the few cancer centers that offers a computer-assisted family history analysis. Our genetic counselors can help men whose family histories suggest an increased risk of hereditary prostate cancer, as well as their family members, to further evaluate their risk.

2. Localized Disease

   As a result of widespread PSA testing, men whose prostate cancer is seemingly confined to the prostate now make up the largest group of prostate cancer patients, and their disease may be curable with therapy directed solely at the prostate. Physicians here carefully assess the patient's disease and stratify his risk to determine the best treatment choice. Treatment ranges from watchful waiting (deferred therapy) to radiation or surgery alone. For patients with localized disease who are unlikely to be cured with these approaches, we offer multimodality therapy combining hormonal and/or systemic therapy and radiation. Researchers here are also beginning to use new combinations for patients with high-risk disease, including chemotherapy with either hormonal therapy, radiation therapy, or surgery in patients whose cancers do not appear to have spread, but who, judging by various test results, have a poor prognosis with radiation therapy or surgery alone.

3. Rising PSA after Primary Therapy

   Men whose PSA levels rise after treatment comprise the second largest segment of the prostate cancer population. For these patients, therapy is directed toward preventing the disease from progressing to the point that it is detectable on a scan or by physical examination or from becoming symptomatic.

   Patients with rising PSAs have unique clinical needs. A rising PSA may be the first indication that their disease has spread outside the prostate, but the increase in prostate antigen level is the only sign of disease activity. As yet there is no standard of care for men in this group, but researchers here at MSKCC are at the forefront of efforts to define which type or combination of treatments are likely to be most effective for these patients. And we offer patients in this group a range of clinical trials of new approaches, from vaccine therapy to hormonal therapy to biologic treatments.

   Therapeutic approaches for men with rising PSAs may also include observation alone or further treatments to the prostate or the prostate bed. Some patients in this group who have undergone prostatectomy will benefit from further radiation therapy and some who have received radiation therapy will benefit from salvage surgery, while others will require systemic treatment. Our team is expert at determining who will benefit most from which approach and has defined optimal care for these patients.

   A recent study, conducted in part at Memorial Sloan-Kettering, suggests that radiation therapy may potentially cure patients whose cancer recurs after prostatectomy. Previous studies suggested that this approach is ineffective, but through this study researchers showed external radiation therapy eradicated residual disease in almost 80 percent of selected patients, with minimal long-term side effects. Our surgeons are also experienced in removing the prostate after other treatments, such as cryotherapy or radioactive seed implants, have failed.

   Memorial Sloan-Kettering's physicians determine as a team optimal treatment for each patient with a rising PSA. Experts in medical oncology, radiation, and surgery all participate in the care of this group of patients.

4. Metastatic Disease before Testosterone-Reducing Therapy

   Physicians here consider a variety of treatment options for men in this group, which includes those who are diagnosed with metastatic disease (cancer that has spread from the prostate to other sites) and whose testosterone levels are normal. Most patients in this group will receive hormonal therapy, which is not curative but can slow the progress of the disease. We are developing alternative, promising ways to deliver hormonal therapy, such as through rapidly cycling delivery, to overcome the survival mechanisms of cancer cells. We are also looking into novel ways to incorporate chemotherapy or to harness the immune system to enhance the effects of hormonal therapy. Our medical oncologists and basic scientists have a number of collaborative research efforts under way to improve the outlook for this group of patients.

5. Metastatic Disease after Testosterone-Reducing Therapy

   Men whose tumors continue to spread after therapy to lower the level of testosterone in the blood have tumors that differ on a molecular level from other metastatic prostate tumors.

   Treatments for this group of patients can include additional hormonal therapies, chemotherapy, or, for those who are eligible, investigational approaches available through clinical trials. Treatments are tailored to the individual based on the aggressiveness of his cancer and the predicted molecular profile of his disease. Standard therapies for patients with metastatic disease who do not respond to hormonal treatments are not curative but are designed to slow progression of the disease.

   Patients in this state are likely to experience side effects and symptoms from metastatic disease. A team of medical oncologists, psychiatrists, pain and palliative care specialists, surgeons, and radiation oncologists work together to treat the physical and psychological effects of disease among these patients.

   Complications of metastatic disease are often related to bone metastases. Medical oncologists can protect bones from disease and from the effects of hormonal therapies.

Find a Clinical Trial Find out about new research studies for prostate cancer more

A host of new treatments that build on chemotherapies and on our understanding of the disease are under investigation here, and our group has led the national effort on the best ways to conduct these trials. Approaches include new chemotherapies, drugs that target the mechanisms that stimulate cancer growth, agents that specifically target prostate cancer cells in bone, and methods of harnessing the immune system to recognize and attack the cancer. We are also exploring new, noninvasive methods of defining the biology of a patient's prostate cancer, using novel imaging techniques. Our group will guide the patient through the often confusing process of choosing a clinical trial based on his lifestyle, medical needs, and the biology of his disease.