1. Steven Joniau Filip Ameye
Implementation of nomograms
into clinical practice
Steven Joniau
Filip Ameye

2. 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

3. 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

4. Predictive accuracy of existing nomograms
Chun F et al. World J Urol 2007

5. 86% 11% 3% Question: Are you? Urologist Radiation oncologist
Medical oncologist
Urologist
Radiation oncologist
Medical oncologist
86%
11% 3%
You have 10
seconds

6. Question for Urologists: do you have access to robot-assisted surgery ?
Yes No
Yes No
37%
63%
You have 10
seconds

7. 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

8. 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

9. Final stage is T3a N0 M0 Final stage is T3a N0 M0
Question: What are the chances this patient has
extraprostatic extension ?
25%
50%
75%
100%
25%
50%
75%
100%
20%
38%
39% 3%
You have 10
seconds

10. Partin tables are not appropriate for staging T3a cancers!!!
NCCN, Practice Guidelines in Oncology, 2005 10

11. T3 pre-treatment table
200 pts with clinical unilateral T3a disease - RP and bilateral LN dissection
Gleason
pT stage
PSA (ng/mL)
≤ 10
10 – 20
≥ 20
≤ 7 (3+4)
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)
≥ 7 (4+3)
31 (15-46)
20 (7-36)
9 (2-21)
54 (37-71)
47 (30-65)
23 (9-43)
12 (4-25)
26 (12-46)
44 (19-69)
3 (0-10)
7 (0-17)
24 (0-55)
Moet besteld
Joniau S et al. Eur Urol 2007;51:388–96 11

12. Final stage is T3a N0 M0 Final stage is T3a N0 M0
Question:What are the chances this patient has lymph node involvement ?
< 10%
10 – 20%
20 – 50%
> 50%
< 10%
10 – 20%
20 – 50%
> 50%
11%
43%
43% 0% 3%
You have 10
seconds

13. Nomogram: Kattan MSKCC
Memorial Sloan Kettering Cancer Center Web Site 13

14. A small exercise… Patient XY PSA 6.4 cT2a
Biopsy Gleason score 6 on biopsies

15. What is the risk of… ECE? SVI invasion? pN+? 20% 40% 60% 80%
20% 40% 60% 80%
SVI invasion?
5% 10% 15% 20%
pN+?
2% 4% 6% 8%

16. What is the risk of… ECE? SVI invasion? pN+? 20% 40% 60% 80%
20% 40% 60% 80%
SVI invasion?
5% 10% 15% 20%
pN+?
2% 4% 6% 8%

17. What is the risk of… ECE? SVI invasion? pN+? 20% 40% 60% 80%
20% 40% 60% 80%
SVI invasion?
5% 10% 15% 20%
pN+?
2% 4% 6% 8%

18. What is the risk of… ECE? SVI invasion? pN+? 20% 40% 60% 80%
20% 40% 60% 80%
SVI invasion?
5% 10% 15% 20%
pN+?
2% 4% 6% 8%

19. What is the risk of biochemical relapse after surgery…
25% 50% 75% 100%

20. What is the risk of biochemical relapse after surgery…
25% 50% 75% 100%

22. A small exercise… Patient YY PSA 8.6 cT2c
Biopsy Gleason score 7 on biopsies

23. What is the risk of… ECE? SVI invasion? pN+? 20% 40% 60% 80%
20% 40% 60% 80%
SVI invasion?
5% 10% 15% 20%
pN+?
2% 4% 6% 8%

24. What is the risk of… ECE? SVI invasion? pN+? 20% 40% 60% 80%
20% 40% 60% 80%
SVI invasion?
5% 10% 15% 20%
pN+?
2% 4% 6% 8%

25. What is the risk of… ECE? SVI invasion? pN+? 20% 40% 60% 80%
20% 40% 60% 80%
SVI invasion?
5% 10% 15% 20%
pN+?
2% 4% 6% 8%

26. What is the risk of… ECE? SVI invasion? pN+? 20% 40% 60% 80%
20% 40% 60% 80%
SVI invasion?
5% 10% 15% 20%
pN+?
2% 4% 6% 8%

27. What is the risk of biochemical relapse after surgery…
25% 50% 75% 100%

28. What is the risk of biochemical relapse after surgery…
25% 50% 75% 100%

32. 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)

33. 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!!!

34. 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

35. 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

36. 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

37. What do we need in the future?
Ultimately, improved imaging studies and high-throughput 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