Formalized prediction of clinically significant prostate cancer: is it possible?

Abstract

Greater understanding of the biology and epidemiology of prostate cancer in the last several decades have led to significant advances in its management. Prostate cancer is now detected in greater numbers at lower stages of disease and is amenable to multiple forms of efficacious treatment. However, there is a lack of conclusive data demonstrating a definitive mortality benefit from this earlier diagnosis and treatment of prostate cancer. It is likely due to the treatment of a large proportion of indolent cancers that would have had little adverse impact on health or lifespan if left alone. Due to this overtreatment phenomenon, active surveillance with delayed intervention is gaining traction as a viable management approach in contemporary practice. The ability to distinguish clinically insignificant cancers from those with a high risk of progression and/or lethality is critical to the appropriate selection of patients for surveillance protocols versus immediate intervention. This chapter will review the ability of various prediction models, including risk groupings and nomograms, to predict indolent disease and determine their role in the contemporary management of clinically localized prostate cancer.

Figure 1

Nomogram predicting the presence of indolent prostate cancer (pathological Gleason score ≤3+3, cancer volume <0.5 ml, organ-confined) based on pretreatment PSA level (Pre.Tx.PSA), clinical stage (Clin.Stage), primary (Pri.Bx.Gl) and secondary (Sec.Bx.Gl) biopsy, Gleason grade, prostate volume by ultrasound (U/S Vol), length of cancer (mm) in biopsy specimens (mm Cancer) and length of non-cancer (mm) in biopsy specimens (mm nonCancer). PSA, prostate-specific antigen.

Figure 2

Nomogram for predicting 10-year disease-specific survival for men with localized prostate cancer who are initially managed with a deferred treatment strategy. The parameters included in the nomogram are clinical stage, method of diagnosis (needle biopsy (BX_NDL) vs. transurethral resection of the prostate (TURP)), percentage of cancer in the biopsy specimen, PSA level at diagnosis, age at diagnosis, the use of early androgen deprivation therapy (within 6 months of diagnosis) and biopsy Gleason score. 120-Mo DSS Prob., 120 months disease-specific survival probability. PSA, prostate-specific antigen.