How and when to use nomograms for counseling patients with prostate cancer ?
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How and when to use nomograms for counseling patients with prostate cancer ? By the BAU Working Group of Urology
Patient counselling
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• 62 years old
• PSA 8,3 ng/ml
• DRE, benign prostatic hypertrophy
• Ultrasound (+)
12 biopsies :
2 positive on right for a Gleason 7 (3+4) in 25 and 35% of the sample.
Patient is concerned and is looking at more information, about which treatment to choose, is think about a radical…
He is discussing the need for a extended lymph nodes dissection.
Doctors’ attitude
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Le malade: Je n’ai rien moi, monsieur le docteur.
Knock: Qu’est ce que vous en savez.
Knock ou le triomphe de la médecine, Jules Romain, Acte 2 scène VI
Unidirectional, paternalistic ‘expert’ physician judgement
Personal physician bias Historical, no controlled data and
attitudes Overall average outcome
prediction
“Health care is changing fast and patients' experiences and expectations are also changing
Patients no longer see themselves as passive recipients of care: increasingly they expect to be involved in all decisions that affect them. ”
The European Patient Of The Future (State of Health) by Angela Coulter and Helen Magee,
Open University Press, 2003.
Patient’s expectation
Tailor based approach
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Bi directional Patient preference Evidence based data Individualised outcome
prediction and prognosis
Patient counselling
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• 62 years old
• PSA 8,3 ng/ml
• DRE, small nodule (0,7 mm ) in the right prostatic lobe
• Ultrasound (+)
12 biopsies :
2 positive on right for a Gleason 7 (3+4) in 25 and 35% of the sample.
Example : what is the risk of lymph nodes invasion ?
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What are the different level of EBM supported prediction ?
Risk groupings and probability tablesClassification and regression tree(CART)
analysisNomogramsArtificial neural networks (ANN)
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Risk Grouping
Patients are “group” according to several prognostic factors into “risk category”
Univariate or multivariate regression analysis are then performed to estimate the % of occurence of the endpoint.
Ex: Partin table
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Probability tables
Partin table
Parker table for risk of death in untreated men with PCa
PCa deaths
Other cause of death
C. Parker et al. British Journal of Cancer (2006) 94, 1361 – 1368
Stephenson nomogram
Stephenson et al. Clin Oncol 25:2035-2041, 2007
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Risk GroupingLimitations
Category summarize cohorts of patients Increment in category may lead to
overestimation of true frequency of endpoint
T1c, Gleason 3+4 Risk of (+) LN
PSA 5,9 ng/dl 8 %
PSA 6,1 ng/dl 12 %
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Nomograms - definition
Statistical definition Graphical representation of a mathematical formula or
algorithm Incorporating several predictors modeled as continuous
variables To predict a particular end point Using traditional statistical methods
– Multivariable logistic regression
– Cox proportional hazard analysis
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Ex Kattan nomograms for predicting prostate-specific antigen recurrence after Radical prostatectomy
Nomogram allows progressive changes of the variables
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Nomogram allows progressive changes of the variables
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Nomogram allows progressive changes of the variables
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Predictive tool and nomogram criteria
Cohorts Developmental vs control
Validation Internal vs external
Predictive accuracy Discrimination and calibration
Generalizability Level of complexity Head-to-head comparison
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Nomograms and cohorts
Cohort Developmental cohort
– Patient study population > Initial statistical patient sample> Single center of excellence series and/or> Data of high volume surgeons/pathologists from highly specialized tertiary care
centers Control cohort
– Control population to test the model and confirm initial predictive accuracy> Internal and/ or external cohort
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Nomograms and validation
Validation Internal validation
– Specific statistical methods, f.e bootstrapping External validation
– Ideal Gold Standard method of validation– Single or multicenter,same/different level of care
Validation end points Predictive accuracy Discrimination and calibration ability
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Artificial neural networks
Neural networks Layers of nodes
– Input, hidden, output
Dendrites:input– Interconnections by weigthed connection
lines
Axons : output Computational model
High complexity
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Nomograms for predicting prostate-specific antigen recurrence
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Nomograms limitations
Retrospective statistical approachDespite prospective data collection
Modeling criteriaModel selection criteria exclude certain other patient
subgroups Total PSA
Total PSA is an important variable in most nomograms– Lack of specificity– Testing variability ( 30%)– Stage migration
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Nomograms limitations
ContemporaneityTool development in non-contemporary situations
– Stage migration/ screen detected populations– Diagnostic and therapeutic standards
– E.g. sextant biopsies vs 10 -12 core biopsies– Dose of radiotherapy– Surgical standards– ….
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Ex of contemporary impactBriganti Nomogram
ContemporaneityTool development in non-contemporary situations
– Stage migration/ screen detected populations– Diagnostic and therapeutic standards
– E.g. sextant biopsies vs 10 -12 core biopsies– Dose of radiotherapy– Surgical standards– ….
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Nomogram predicting the probability of lymph node invasion in patients undergoing extended pelvic lymphadenectomy
Briganti et al. Eur Urol 2007
Change in the technique induce a 20% risk increase…
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Nomograms for prediction of prostate cancer at needle biopsy
Karakiewicz PI and Hutterer GC (2008) Predictive models and prostate cancer. Nat Clin Pract Urol 5: 82–92
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Prediction of specific pathological features of clinically localized prostate cancer (before treatment)
Karakiewicz PI and Hutterer GC (2008) Predictive models and prostate cancer
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Prediction of biochemical recurrence with preoperative variables
Karakiewicz PI and Hutterer GC (2008) Predictive models and prostate cancerNat Clin Pract Urol 5: 82–92 doi:10.1038/ncpuro0972
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Predictive accuracy of existing nomograms
Chun F et al. World J Urol 2007
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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 a real patient-specific staging and prognostication, and allow patient-tailored treatment decisions to be made
In the meantime, nomograms are the best possible alternative and should be actively implemented in EAU prostate cancer guidelines