Nomogram may lower unneeded biopsies in men on AS

A new nomogram may help better predict the risk of disease progression in men who are being managed by active surveillance for low-risk prostate cancer.

Editor's note: This article has been updated since its original publication to include additional study data and commentary from the author/presenter.

Orlando, FL-A new nomogram may help better predict the risk of disease progression in men who are being managed by active surveillance (AS) for low-risk prostate cancer.

The nomogram, which researchers say may be a new tool for eliminating unnecessary biopsy and biopsy-related complications, was presented at the AUA annual meeting in Orlando, FL.

Dr. Sternberg“There are a few predictive models out there for patients on active surveillance, but the main thing we did was change and add surveillance data so that all the biopsies that have been performed to date are included. The risk of a patient changes over time. The more biopsies he gets and the more data we have on those biopsies allows us to calculate his risk of progression and reclassify and tailor his surveillance protocol in the future,” said first author Itay Sternberg, MD, a urologic oncology fellow at Memorial Sloan Kettering Cancer Center, New York, who worked on the study with Karim Touijer, MD, and co-authors.

Dr. Sternberg and his co-authors conducted a retrospective review of all men enrolled in the AS program between 1993 and 2012 at Memorial Sloan Kettering. Men included in the analysis met inclusion criteria for AS (cT1 or cT2s, PSA <10.0 ng/mL, Gleason score of 6 or less, no more than three positive cores, and no more than 50% involvement in any single core). The investigators analyzed demographic data (age), clinical data (PSA levels and clinical stage), and pathologic data (biopsy features) in order to develop the nomogram for predicting progression-free probability.

There were 1,095 patients enrolled in the AS program, and 680 patients met the inclusion criteria for AS. The mean age of the men was 66 years. During a median follow-up of 3 years, 101 patients progressed (87 patients were upgraded to Gleason 7 or higher and 14 patients progressed based on higher volume of disease). The authors used multivariable logistic regression analysis to model the association between each risk variable and disease progression.

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Older age among progression predictors

The authors found that older age, higher baseline PSA levels, a greater number of initial positive cores, and a higher initial involvement of a single core were associated with a higher risk for disease progression.

“You can’t follow every patient in the same manner. It is a dynamic process, and you have to tailor the protocol to the specific patient. The nomogram gives each patient his own risk profile, and when you weigh the risks against the possible harms of biopsies, etc., you can make an informed decision on whether you continue to have another biopsy or maybe you forgo a biopsy and continue surveillance without a biopsy,” Dr. Sternberg told Urology Times.

“Within the low-risk active surveillance patient population, the risk of progression/re-classification is heterogeneous,” added Dr. Touijer. “Our understanding of this risk changes at each time point as we obtain additional information. Thus, it is important to apply a predictive model to re-assess the risk every time we get more information and adapt the surveillance protocol accordingly.”UT