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Nomograms for prostate cancer—is their use evidence-based?

Nature Clinical Practice Urology volume 2, pages 462–463 (2005)Cite this article

Nomograms are widely used in urology. These algorithms incorporate multiple independent prognostic factors into a mathematical model in order to predict the outcome of individual patients. The first nomograms to be developed, and still the most widely used, combine clinical stage, Gleason grade, and preoperative prostate-specific antigen (PSA) to predict pathologic stage in men with prostate cancer.1 Nomograms have also been widely used to predict recurrence following radical prostatectomy, external beam radiotherapy, and brachytherapy, on the basis of pretreatment and post-treatment clinical and pathologic factors. Although they are most commonly used to discuss prognosis with patients, staging nomograms have also been used to justify wider excision margins or lymph-node dissection in high-risk patients,2 and their use has been recommended in clinical practice guidelines for initial clinical management and staging evaluation of patients with prostate cancer. In summary, these clinical prediction tools—statistical models based on the outcomes of large patient series—are widely used to assess a patient's level of risk before making important decisions about treatment modalities and their delivery.

There is, however, a fundamental epistemological problem that raises concern about uncritical use of this widely applied approach. Predictions based on previous case series are derived from a process of induction: what we see as a view into the future is in reality only a view of the past. The validity of these predictions is dependent on the stability of the relationship between predictors and outcome over place and time. Can this be relied upon? The risk profile of the populations to which predictions are applied can differ substantially from the original (source) population. Furthermore, changes (hopefully improvements) in the effectiveness of treatments could render predictions unduly pessimistic. Interestingly, changes in practice resulting from the use of nomograms, such as wider excision margins in high-risk patients, could influence the accuracy of algorithms. Any factor which influences disease outcome and changes over time could alter the relationships underlying these models.

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Authors and Affiliations

  1. Repatriation General Hospital,

    Alan MF Stapleton

  2. Flinders University of South Australia, Adelaide, Australia

    Alan MF Stapleton

  3. Urology Unit of the Repatriation General Hospital,

    Carole B Pinnock

  4. Flinders University of South Australia, Adelaide, Australia

    Carole B Pinnock

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  1. Alan MF Stapleton
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  2. Carole B Pinnock
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Correspondence to Carole B Pinnock.

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The authors declare no competing financial interests.

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Stapleton, A., Pinnock, C. Nomograms for prostate cancer—is their use evidence-based?. Nat Rev Urol 2, 462–463 (2005). https://doi.org/10.1038/ncpuro0300

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