Implementation of nomograms
into clinical practice
Steven Joniau
Filip Ameye
Clinical value of nomograms
• Important role in the process of decision aid and
patient counseling
• Predictive accuracy
– Statistical vs clinical significance
• Accuracy Increase of 12% = 120 out of 1000 patients are
provided with accurate prediction
• Medical, ethical, economical,… implications
– Uplevelling by introduction of novel biomarkers
Why should we use nomograms?
• Nomograms have been developed to accomodate stage
migration
– Not only take into account PSA, Gleason score, clinical stage
– Also account for number of biopsies, prior biopsies, etc.
– Use updated data sets
– Should be validated, ideally by external validation
Predictive accuracy of existing nomograms
Chun F et al. World J Urol 2007
Question: Are you?
1 Urologist
2 Radiation oncologist
11%
3 Medical oncologist
3%
86%
Question for Urologists: do you have
access to robot-assisted surgery ?
1 Yes
2 No
37%
63%
Clinical case
• 62 years old, married,
sexually active
• First PSA: 13.5 ng/ml. PSA
years before 9 ng/ml
• DRE: nodule of the right
prostatic lobe T3a
Clinical case
• Large hypoechoic zone in postero-basal
right
• 12 biopsies
 Right side: 6/6 positives in 3 sextants
Gleason 3+4
 Left side : 2/6 positives Gleason 4+4
Final stage is T3a N0 M0
Question: What are the chances this patient has
extraprostatic extension ?
1
25%
20%
2
50%
38%
3
75%
39%
4
100%
3%
Partin Tables
Partin tables are not appropriate for staging T3a cancers!!!
NCCN, Practice Guidelines in Oncology, 2005
T3 pre-treatment table
200 pts with clinical unilateral T3a disease - RP and bilateral LN
dissection
Gleason pT stage
≤ 7 (3+4)
PSA (ng/mL)
≤ 10
10 – 20
≥ 20
pT2
29 (20-39) 21 (12-33)
14 (5-27)
pT3a
65 (55-74) 63 (49-76) 46 (30-62)
pT3b
5 (2-10)
14 (5-24)
32 (18-48)
pT4
1 (0-2)
2 (0-8)
8 (0-16)
pT2
31 (15-46)
20 (7-36)
9 (2-21)
54 (37-71) 47 (30-65)
23 (9-43)
≥ 7 (4+3) pT3a
pT3b
pT4
12 (4-25)
3 (0-10)
Joniau S et al. Eur Urol 2007;51:388–96
26 (12-46) 44 (19-69)
7 (0-17)
24 (0-55)
Final stage is T3a N0 M0
Question:What are the chances this patient has
lymph node involvement ?
1
< 10%
11%
2
10 – 20%
43%
3
20 – 50%
43%
4
> 50%
3%
Nomogram: Kattan MSKCC
Memorial Sloan Kettering Cancer Center Web Site
A small exercise…
• Patient XY
– PSA 6.4
– cT2a
– Biopsy Gleason score 6 on biopsies
What is the risk of…
• ECE?
20%
40% 60% 80%
• SVI invasion?
5%
10% 15% 20%
• pN+?
2%
4%
6%
8%
What is the risk of…
• ECE?
20%
40% 60% 80%
• SVI invasion?
5%
10% 15% 20%
• pN+?
2%
4%
6%
8%
What is the risk of…
• ECE?
20%
40% 60% 80%
• SVI invasion?
5%
10% 15% 20%
• pN+?
2%
4%
6%
8%
What is the risk of…
• ECE?
20%
40% 60% 80%
• SVI invasion?
5%
10% 15% 20%
• pN+?
2%
4%
6%
8%
What is the risk of biochemical relapse
after surgery…
25%
50% 75% 100%
What is the risk of biochemical relapse
after surgery…
25%
50% 75% 100%
A small exercise…
• Patient YY
– PSA 8.6
– cT2c
– Biopsy Gleason score 7 on biopsies
What is the risk of…
• ECE?
20%
40% 60% 80%
• SVI invasion?
5%
10% 15% 20%
• pN+?
2%
4%
6%
8%
What is the risk of…
• ECE?
20%
40% 60% 80%
• SVI invasion?
5%
10% 15% 20%
• pN+?
2%
4%
6%
8%
What is the risk of…
• ECE?
20%
40% 60% 80%
• SVI invasion?
5%
10% 15% 20%
• pN+?
2%
4%
6%
8%
What is the risk of…
• ECE?
20%
40% 60% 80%
• SVI invasion?
5%
10% 15% 20%
• pN+?
2%
4%
6%
8%
What is the risk of biochemical relapse
after surgery…
25%
50% 75% 100%
What is the risk of biochemical relapse
after surgery…
25%
50% 75% 100%
EAU prostate cancer guidelines
• Use of nomograms is only included 3 times
– Preoperative staging (Kattan nomogram, Partin
tables (= look-up tables))
– Indication of extended lymph node dissection
(Briganti nomogram)
– Indication of nerve-sparing surgery (Partin tables)
• So, clearly the use of nomograms has not yet
been implemented sufficiently into routine
urological practice!!!!!
• The reason for this is that studies providing EBM
on the advantage of using nomograms over
clinical judgement are virtually ABSENT!!!
Why should nomograms be implemented
into clinical practice?
• Appropriate patient couseling and decision-making
• Better disease prognostication
• Follow-up scheduling
• Selection of appropriate patients for clinical trials
Why should nomograms be implemented
into guidelines?
• Currently, the only method through which we can
compare biochemical recurrence rates after
alternative treatment modalities with
brachytherapy, external beam radiotherapy, and
radical prostatectomy are nomograms
What do we need in the future?
• Update nomograms to contemporary situation
• Head-to-head comparisons between nomograms to select the
best-suited model in selected fields of PCa outcomes
• We need nomograms that provide accurate predictions of hard
clinical endpoints (clinical failure, death from the disease)
• We need nomograms that accurately predict death from
comorbid disease in men with localized disease selected for
radical treatment
• We need nomograms that predict treatment-related toxicity
What do we need in the future?
• Ultimately, improved imaging studies and highthroughput genomics may replace the use of
nomograms, as they will provide an real patient-specific
staging and prognostication, and patient-tailored
treatment decisions
• In the meantime, nomograms are the best possible
alternative and should be actively implemented in
urological practice